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HA.~DBOOK OF LOCAL ANESTHESIA


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Contributors

Daniel L Orr II, BS, DDS, MS (Anesthesiology), Mark N. Hochman, DDS


PhD, JD, MD Private Practice Limited to Periodontics
Professor and Director Orthodontics and Implant Dentistry
Oral and Maxillofacial Surgery and Advanced Pain Control Specialized Dentistry of New York
University of Nevada Las Vegas School of Dental Medicine New York City, New York
Las Vegas, Nevada Clinical Associate Professor
Clinical Professor New York University
Oral and Maxillofacial Surgery College of Dentistry
University of Nevada School of Medicine New York City, New York
Las Vegas, Nevada Clinical Consultant
Milestone Scientific, Inc.
Livingston, New Jersey

vii
Preface

The sixth edition of Handbook of Local Anesthesia! switch) to increase patient comfort during injection, decrease
As happened with previous editions, I truly find it hard to onset time of anesthesia, and, perhaps, increase the depth
comprehend how many years have transpired since the 1st of anesthesia; phentolamine mesylate (the local anesthetic
edition was published in 1978. It has been 8 years since the "OFF" switch) giving the doctor the opportunity to signifi­
fifth edition and in this time there have been a significant cantly minimize the duration of a patients residual soft tissue
number of changes, many of them advances, in the art and anesthesia, thereby minimizing the risk of self-inflicted soft
science of pain control in dentistry. tissue injury.
Though the drugs remain the same---articaine HCl, bupi­ I have asked Dr. Mark Hochman to rewrite the discussions
vacaine HCl, lidocaine HCl, mepivacaine HCl, and prilocaine in this edition on C-CLAD devices (Chapter 5-The Syringe)
HCl-the years since the fifth edition have seen the introduc­ and the local anesthetic techniques associated with it (Chapter
tion and refinement of drugs and devices which work to help IS-Supplemental Injections and Chapter 20---Future Con­
the dental profession come ever closer to the twin goals of siderations). Dr. Hochman has been intimately involved with
truly pain free dentistry and truly pain free local anesthetic the development of C-CLAD since the mid-1990s and is
injections. the author of a number of refereed papers on the subject
As I have stated repeatedly in previous editions, "Local including two injection techniques---AMSA (anterior middle
anesthetics are the safest and the most effective drugs avail­ superior alveolar nerve block) and P-ASA (palatal-anterior
able in all of medicine for the prevention and the management superior alvelar nerve block) that were developed as a result
of pain. Indeed, there are no other drugs that truly prevent of his research into computer delivery of local anesthetics.
pain; no other drugs which actually prevent a propagated A DVD accompanied the fifth edition of Local Anesthesia.
nociceptive nerve impulse from reaching the patient's brain, It followed the structure of the textbook, providing clinical
where it would be interpreted as pain. Deposit a local anes­ demonstrations of the techniques and concepts presented in
thetic drug in close proximity to a sensory nerve and clinically the text. The DVD has proven to be a highly effective teaching
adequate pain control will result in essentially all clinical device and is used, both legally and (sadly) illegally, by stu­
situations." dents, dentists and dental hygienists throughout the world.
Find the nerve with a local anesthetic drug and pain control A supplemental disk has been incuded with the original
is virtually assured. Yet in certain clinical situations "finding 2-disk set which accompanies this sixth edition. The disk pres­
the nerve" remains a vexing problem. This is especially so in ents clinical updates on a number of the newer additions to
the mandible, primarily permanent mandibular molars. Over the local anesthetic armamentarium. It is my feeling, as an
my 39 years as a teacher of anesthesia in dentistry I and my educator that the combination of the written text plus the
dentist anesthesiologist colleagues have worked at "fixing" this visual impact of the DVD provides a more optimal learning
problem. experience for all who come to study this critically important
Have we succeeded? Not yet. subject.
Are we getting close to a solution? Yes. Feedback from readers of this textbook is always appreci­
This sixth edition of Local Anesthesia includes new and/ or ated. Should errors be noted, or suggestions for improvement
expanded discussions of the periodontal ligament (PDL) be made, contact me at malamed@usc.edu.
injection-including the use of computer-controlled local
anesthetic delivery (C-CLAD) systems for PDL (and other Stanley F. Malamed
injections); the administration of the local anesthetic articaine
HCl by mandibular infiltration in the adult mandible; buffer­ October 2011
ing of local anesthetic solutions (the local anesthetic "ON" Los Angeles, California, USA

ix
Acknowledgments

The people involved with the video production of the new supplemental DVD cannot receive
enough thanks: Dr. Joseph Massad and his excellent team at Millennium Productions.
Thanks, too, to the manufacturers of local anesthetic drugs and devices in North America,
including Beutlich Pharmaceuticals; Dentsply; Kodak (Cook-Waite); Midwest; Milestone Scientific;
Novocol; Septodont, Inc; and Sultan Safety, LLC, for their assistance in supplying photographs and
graphics for use in this edition.
I also want to thank Brian S. Loehr, Senior Content Development Specialist; Rachel E. McMullen,
Senior Project Manager; and John J. Dolan, Executive Content Strategist, from Mosby (an affiliate
of Elsevier) who had the unenviable task of dealing with a frequently lazy, usually hard-to-reach
author. Their perseverance-once again-has paid off with this sixth edition.
Finally, I wish to thank the many members of our profession, the dentists and dental hygienists,
who have provided me with written and verbal input regarding prior editions of this textbook.
Many of their suggestions for additions, deletions, and corrections have been incorporated into this
new text. Thanks to you all!
Stanley F. Malamed
December 2011
Los Angeles, California

xi
Contents

PART I THE DRUGS


1 Neurophysiology,2
2 Pharmacologyof LocalAnesthetics,25
3 Pharmacologyof Vasoconstrictors,39
4 ClinicalAction of SpecificAgents, 52

PART II THE ARMAMENTARIUM


5 The Syringe,78
Marie N. Hochman
6 The Needle,92
7 The Cartridge, 101
8 Additional Armamentarium, 110
9 Preparationof the Armamentarium, 113

PART Ill TECHNIQUES OF REGIONAL ANESTHESIA IN DENTISTRY


10 Physicaland PsychologicalEvaluation, 124
11 BasicInjection Technique,157
12 Anatomic Considerations,169
13 Techniquesof Maxillary Anesthesia, 188
14 Techniquesof Mandibular Anesthesia,225
15 SupplementalInjection Techniques,253
Marie N. Hochman
16 Anesthetic Considerationsin Dental Specialties,277

PART IV COMPLICATIONS, LEGAL CONSIDERATIONS, QUESTIONS,


AND FUTURE
17 Local Complications,292
18 SystemicComplications,311
19 Legal Considerations,341
Daniel l. Orr //.
20 FutureTrendsin PainControl, 356
Marie N. Hochman
21 Questions,380

xiii
New to this Edition
< I
' J'

DVD SUPPLEMENT NEW INFORMATION


A supplemental disk has been added to the original 2-disk set. Updated discussions of the armamentarium needed to
The new DVD supplement presents clinical updates on a succeed in local anesthesia delivery
number of the newer additions to the local anesthetic
armamentarium, including the local anesthesia "ON" and
"OFF" switches, and Computer-Controlled Local Anesthetic
Delivery (C-CLAD).
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Computer-controlled local anesthetic delivery (C-CLAD)


systems

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xiv
New to this Edition xv

NEW ILLUSTRATIONS IDENTIFY CLINICALLY IMPORTANT ANATOMY

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IN THIS PART
Chapter 1 Neurophysiology
Chapter 2 Pharmacology of Local Anesthetics
Chapter 3 Pharmacology of Vasoconstrictors
Chapter 4 Clinical Action of Specific Agents

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PART

The Drugs

In the first section of this book, the pharmacologicand clinicalproperties of the classesof drugs known
as local anesthetics (Chapter 2) and vasoconstrictors (Chapter 3) are discussed Knowledgeof both the
pharmacologic and clinicalproperties of these drugs, by all persons permitted to administer them, is
absolutelyessentialfor their safeuse and for a better understanding of those potentiallylife-threatening
systemic reactions associated with their administration. Emphasis is placed on local anesthetic drug
combinations currently used in anesthesia in dentistry in North America (Chapter 4).
Chapter 1provides a background for understanding how local anestheticswork to transiently block
nerve conduction, thus preventing pain from being experienced. The anatomy and physiology of
normal neurons and nerve conduction are reviewed as a background for the discussion, which, in
subsequent chapters, takes up the pharmacology and clinical actions of various specificagents.

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T

Neurophysiology
' I •I

use as a local anesthetic. Toxicityvaries greatly among the


DESIRABLE PROPERTIES OF
local anesthetics currently in use. Toxicityis discussedmore
LOCAL ANESTHETICS
thoroughly in Chapter 2. Although it is a desirable charac­
Local anesthesia has been defined as loss of sensation in a teristic,not all local anestheticsin clinicaluse today meet the
circumscribedarea of the body causedby depressionof exci­ criterion of being effective,regardlessof whether the drug is
tation in nerve endings or inhibition of the conduction injected or applied topically. Several of the more potent
process in peripheral nerves.1An important feature of local injectable local anesthetics (e.g., procaine, mepivacaine)
anesthesia is that it produces this loss of sensation without prove to be relativelyineffectivewhen applied topically to
inducing loss of consciousness.In this one major area, local mucous membranes. To be effectiveas topical anesthetics,
anesthesia differs dramatically from general anesthesia. these drugs must be applied in concentrations that prove to
Many methods are used to induce local anesthesia: be locally irritating to tissues while increasing the risk of
1. Mechanicaltrauma (compression of tissues) systemic toxicity. Dyclonine, a potent topical anesthetic, is
2. Lowtemperature not administered by injection because of its tissue-irritating
3. Anoxia properties. Lidocaineand tetracaine, on the other hand, are
4. Chemical irritants effective anesthetics when administered by injection or
5. Neurolytic agents such as alcohol and phenol topical application in clinically acceptable concentrations.
6. Chemical agents such as local anesthetics The last factors-rapid onset of action and adequate dura­
However,only those methods or substances that induce tion of clinicalaction-are met satisfactorilyby most of the
a transient and completelyreversiblestate of anesthesiahave clinically effective local anesthetics in use today. Clinical
application in clinicalpractice. Followingare those proper­ duration of action does vary considerablyamong drugs and
ties deemed most desirable for a local anesthetic: also among different preparations of the same drug, as well
1. It should not be irritating to the tissue to which it is as by the type of injection administered (e.g.,nerve block vs.
applied. supraperiosteal). The duration of anesthesia necessary to
2. It should not cause any permanent alteration of nerve complete a procedure is a major consideration in the selec­
structure. tion of a local anesthetic.
3. Its systemictoxicity should be low. In addition to these qualities, Bennett2lists other desir­
4. It must be effectiveregardlessof whether it is injected able properties of an ideal local anesthetic:
into the tissue or is applied locallyto mucous 7. It should have potency sufficientto give complete
membranes. anesthesiawithout the use of harmful concentrated
5. The time of onset of anesthesia should be as short as solutions.
possible. 8. It should be relativelyfree from producing allergic
6. The duration of action must be long enough to permit reactions.
completion of the procedure yet not so long as to 9. It should be stable in solution and should readily
require an extended recovery. undergo biotransformation in the body.
Most local anesthetics discussed in this section meet the 10. It should be sterile or capable of being sterilizedby
first two criteria:They are (relatively)nonirritating to tissues heat without deterioration.
and are completelyreversible.Of paramount importance is No local anesthetic in use today satisfiesall of these cri­
systemictoxicity,becauseallinjectableand most topicallocal teria; however,all anesthetics do meet a majority of them.
anestheticsare eventuallyabsorbed from their site of admin­ Researchis continuing in an effort to produce newer drugs
istration into the cardiovascularsystem.The potential toxic­ that possessa maximum of desirablefactors and a minimum
ity of a drug is an important factor in its consideration for of negativeones.
2

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CHAPTER1 Neurophysiology 3

"dies,"never reaching the brain, and pain does not occur


FUNDAMENTALS OF IMPULSE GENERATION
(Fig. 1-2).
AND TRANSMISSION
How,in fact, do local anesthetics,the most used drugs in
The discoveryin the late 1800sof a group of chemicalswith dentistry, function to abolish or prevent pain? Followingis
the ability to prevent pain without inducing loss of con­ a discussionof current theories seekingto explain the mode
sciousnesswas one of the major steps in the advancement of of action of local anesthetic drugs. To understand their
the medicaland dental professions.Forthe firsttime, medical action better, however,the reader must havean acquaintance
and dental procedures,could be carried out easilyand in the with the fundamentals of nerve conduction. A reviewof the
absence of pain, a fact that is virtually taken for granted by relevantcharacteristicsand properties of nerve anatomy and
contemporary medical and dental professionals and their physiologyfollows.
patients.
The concept behind the actions of local anesthetics is The Neuron
simple: They prevent both the generation and the conduc­ The neuron, or nerve cell,isthe structural unit of the nervous
tion of a nerve impulse. In effect,local anesthetics set up a system. It is able to transmit messagesbetween the central
chemicalroadblock between the source of the impulse (e.g., nervous system (CNS) and all parts of the body. There are
the scalpel incision in soft tissues) and the brain. Therefore two basic types of neuron: sensory (afferent) and motor
the aborted impulse, prevented from reaching the brain, (efferent). The basic structure of these two neuronal types
cannot be interpreted by the patient as pain. differs significantly(Fig. 1-3).
This is similar to the effect of lighting the fuse on a stick Sensoryneurons that are capableof transmitting the sen­
of dynamite. The fuse is the "nerve,"whereas the dynamite sation of pain consist of three major portions. 3 The periph­
is the "brain:' If the fuse is lit and the flame reaches the eral process (also known as the dendritic zone), which is
dynamite, an explosion occurs (Fig. 1-1). When a nerve is composed of an arborization of free nerve endings, is the
stimulated, an impulse is propagated that willbe interpreted most distal segment of the sensory neuron. These free nerve
as pain when it reachesthe brain. If the fuse is lit, but "water"
(e.g.,local anesthetic) is placed somewherebetween the end
of the fuse and the dynamite stick,the fuse will burn up to
the point of water application and then die out. The dyna­
mite does not explode.When a local anesthetic is placed at
some point between the pain stimulus (e.g., the drill) and
the brain, the nerve impulse is still propagated and travels
up to the point of local anesthetic application and then

OWlll


Figure 1-1. The fuse is lit and the flame reaches the dynamite;
Figure 1-2. Localanesthetic is placed at some point between the
pain stimulus and the brain (dynamite). The nerve impulse travels
up to the point oflocal anesthetic application and then "dies,"never
an explosion occurs, and the patient experiencespain. reaching the brain, and pain does not occur.

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4 PART I The Drugs

CNS

Synapse with
I
Skeletal muscle cell
another neuron
A
Cell body

p
E
R
I
p
CNS H
E
Axon or Dendrite or R
y
central process peripheral process

B
Figure 1-3. A, Multipolar motor neuron. B, Unipolar sensory neuron. (From Liebgott B:Anatomical basis of dentistry, ed 2, St Louis,
2001,Mosby.)

endings respond to stimulation produced in the tissues in terminal (or bouton). Axon terminals synapse with muscle
which they lie, provoking an impulse that is transmitted cells (Fig. 1-3,A).
centrally along the axon. The axon is a thin cable-likestruc­
ture that may be quite long (the giant squid axon has been The Axon
measured at 100to 200 cm). At its mesial (or central) end is The single nerve fiber,the axon, is a long cylinder of neural
an arborization similarto that seen in the peripheral process. cytoplasm (axoplasm) encased in a thin sheath, the nerve
However,in this case the arborization forms synapseswith membrane, or axolemma. Neurons have a cell body and a
various nuclei in the CNS to distribute incoming (sensory) nucleus, as do all other cells;however,neurons differ from
impulses to their appropriate siteswithin the CNSfor inter­ other cells in that they have an axonal process from which
pretation. The cell body is the third part of the neuron. In the the cell body may be at a considerable distance. The axo­
sensory neuron described here, the cell body is located at a plasm, a gelatinoussubstance,is separated from extracellular
distance from the axon, the main pathway of impulse trans­ fluidsby a continuous nerve membrane. In some nerves,this
mission in this nerve. The cell body of the sensory nerve membrane is itself coveredby an insulating lipid-rich layer
therefore is not involvedin the processof impulse transmis­ ofmyelin.
sion, its primary function being to provide vital metabolic Current thinking holds that both sensory nerve excitabil­
support for the entire neuron (Fig. 1-3, B). ity and conduction are attributable to changes developing
Nerve cellsthat conduct impulses from the CNS toward within the nerve membrane. The cellbody and the axoplasm
the periphery are termed motor neurons and are structurally are not essential for nerve conduction. They are important,
different from the sensory neurons just described in that however.The metabolic support of the membrane is prob­
their cellbody is interposed between the axon and dendrites. ably derived from the axoplasm.
In motor neurons, the cellbody not only is an integral com­ The nerve (cell) membrane itself is approximately 70
ponent of the impulse transmission systembut alsoprovides to 80 A thick. (An angstrom unit is 1/10,000of a microm­
metabolic support for the cell.Near its termination, the axon eter.) Figure 1-4represents a currently acceptableconfigura­
branches with each branch, ending as a bulbous axon tion. All biological membranes are organized to block the

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CHAPTER1 Neurophysiology 5

diffusion of water-soluble molecules; to be selectively per­ flexiblenonstretchable structure consisting of two layers of
meable to certain molecules via specialized pores or chan­ lipid molecules (bilipid layer of phospholipids) and associ­
nels; and to transduce information through protein receptors ated proteins, lipids, and carbohydrates. The lipids are ori­
responsive to chemical or physical stimulation by neu­ ented with their hydrophilic (polar) ends facing the outer
rotransmitters or hormones (chemical) or light, vibration, surfaceand their hydrophobic (nonpolar) ends projecting to
or pressure (physical).4 The membrane is described as a the middle of the membrane (Fig. 1-4,A). Proteins are visu­
alizedas the primary organizational elementsof membranes
(Fig. 1-4, B).5 Proteins are classifiedas transport proteins
(channels, carriers, or pumps) and receptor sites. Channel
proteins are thought to be continuous pores through the
membrane, allowing some ions (Na+,K,+Ca") to flow pas­
Monolayer of nonlipids
sively,whereas other channels are gated, permitting ion flow
only when the gate is open.4 The nerve membrane lies at the
Biomolecular layers of lipids
interface between extracellularfluid and axoplasm. It sepa­
rates highly diverse ionic concentrations within the axon
from those outside. The resting nerve membrane has an
electrical resistance about 50 times greater than that of the
intracellular and extracellular fluids, thus preventing the
passageof sodium, potassium, and chloride ions down their
concentration gradients. However, when a nerve impulse
passes, electrical conductivity of the nerve membrane
increases approximately 100-fold.This increase in conduc­
tivity permits the passage of sodium and potassium ions
A along their concentration gradients through the nerve mem­
brane. It is the movement of these ions that provides an
immediate source of energy for impulse conduction along
the nerve.
Some nerve fibers are coveredby an insulating lipid layer
of myelin.In vertebrates,myelinatednerve fibers include all
but the smallest of axons (Table 1-1).6 Myelinated nerve
fibers (Fig. 1-5) are enclosed in spirally wrapped layers of
lipoprotein myelin sheaths, which are actually a specialized
form of Schwarm cell. Although primarily lipid (75%),
the myelin sheath also contains some protein (20%) and
carbohydrate (5%).7 Each myelinatednerve fiber is enclosed
B in its own myelin sheath. The outermost layer of myelin
Figure 1-4. A, Configuration of a biological membrane. B, Hetero­ consistsof the Schwanncellcytoplasmand its nucleus.Con­
geneous lipoprotein membrane as suggested by Singer and strictions are located at regular intervals (approximately
Nicholson. (Redrawn from Covino BG,Vassalo HG: Local anesthet­ every 0.5 to 3 mm) along the myelinated nerve fiber.These
ics: mechanisms of action and clinical use, New York, 1976, Grune are nodes of Ranvier, and they form a gap between two
& Stratton.) adjoining Schwann cells and their myelin spirals.8 At these

TABLE 1-1
Classification of Peripheral Nerves According to Fiber Size and Physiologic Properties
Fiber Conduction
Class Subclass Myelin Diameter,µ Velocity, m/s Location Function
A alpha + 6-22 30-120 Afferent to and efferent from Motor, proprioception
muscles and joints
beta + 6-22 30-120 Afferent to and efferent from Motor, proprioception
muscles and joints
gamma + 3-6 15-35 Efferent to muscle spindles Muscle tone
delta + 1-4 5-25 Afferent sensory nerves Pain, temperature, touch
B + <3 3-15 Preganglionic sympathetic Various autonomic functions
c sC - 0.3-1.3 0.7-1.3 Postganglionic sympathetic Various autonomic functions
dgammaC - 0.4-1.2 0.1-2.0 Afferent sensory nerves Various autonomic functions; pain,
temperature, touch
From BerdeCB,StrichartzGR:Localanesthetics.In MillerRD,editor:Anesthesia,ed 5, Philadelphia,2000, ChurchillLlvingstone,pp 491-521.

www.ShayanNemoodar.com
6 PART I The Drugs

Schwanncell

Nodeof Ranvler

Figure 1-5. Structure of a


myelinatednerve fiber. (Redrawn
from de Jong RH: Localanesthet­
ics, St Louis, 1994,Mosby.)

UNMYELINATED from a brief increase in the permeability of the membrane


Schwann cell
to sodium, and usually also from a delayed increase in its
nucleus and permeabilityto potassium.9 Impulses are initiated by chemi­
cytoplasm cal, thermal, mechanical,or electricalstimuli.
Once an impulse is initiated by a stimulus in any particu­
lar nerve fiber, the amplitude and shape of that impulse
remain constant, regardlessof changes in the quality of the
stimulus or in its strength. The impulse remains constant
without losing strength as it passes along the nerve because
the energy used for its propagation is derived from energy
that is released by the nerve fiber along its length and not
Axons
solely from the initial stimulus. de Jong has described
impulse conduction as being like the active progress of a
spark along a fuse of gunpowder," Once lit, the fuse burns
steadilyalong its length, with one burning segment provid­
ing the energy necessary to ignite its neighbor. Such is the
situation with impulse propagation along a nerve.
Axon

Electrophysiology of Nerve Conduction


Following is a description of electrical events that occur
Schwann cells within a nerve during the conduction of an impulse. Subse­
Figure 1-6. Types of Schwarm cell sheaths. (Redrawn from quent sections describe the precise mechanisms for each of
Wildsmith JAW: Peripheral nerve and anaesthetic drugs, Br J these steps.
Anaesth 58:692-700,1986.) A nerve possesses a resting potential (Fig. 1-7, Step 1).
This is a negative electrical potential of -70 mV that exists
across the nerve membrane, produced by differing concen­
nodes, the nerve membrane is exposed directlyto the extra­ trations of ions on either side of the membrane (Table 1-2).
cellular medium. The interior of the nerve is negativerelativeto the exterior.
Unmyelinatednerve fibers (Fig. 1-6) are also surrounded
by a Schwann cell sheath. Groups of unmyelinated nerve Step 1. A stimulus excitesthe nerve,leadingto the following
fibers share the same sheath. The insulating properties of sequence of events:
the myelin sheath enable a myelinated nerve to conduct A. An initial phase of slow depolarization. The electrical
impulses at a much faster rate than an unmyelinated nerve potential within the nerve becomes slightlyless negative
of equal size. (see Fig. 1-7,Step IA).
B. When the falling electricalpotential reaches a critical
Physiology of the Peripheral Nerves level,an extremelyrapid phase of depolarization
The function of a nerve is to carry messagesfrom one part results.This is termed threshold potential; or firing
of the body to another. These messages,in the form of elec­ threshold (see Fig. 1-7,Step lB).
trical action potentials, are calledimpulses. Action potentials C. This phase of rapid depolarization results in a reversal
are transient depolarizations of the membrane that result of the electricalpotential acrossthe nerve membrane

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CHAPTER1 Neurophysiology 7

Extracellularfluid
Na+ ++++ Nerve membrane
vzzzzzzzzj?zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzztf
i<+ ---- Normal
Resting -70 mV
Axoplaam (resting potential)

A Na+ + +++
Firing
i<+ ---- -50 to-60 mV
Step 1, A
and B (slow depolarizationto
V/lZZZ/l/lZZZ/lZZZ/l/lZZZ/lZZZ/l/lZZZ/l/77/lA threshold potential)
Figure 1-7. Top, Restingpotential. Step 1,
A and B, Slow depolarization to threshold.
Step 1, C, Rapid depolarization. Step 2,
C Na+ Repolarization.
Potential
++++
Step 1C +40
(rapid depolarization)

Repolarization
Step2 -60 to-90 mV
V/lZZZ/l/lZZZ/lZZZ/l/lZZZ/lZZZ/l/lZZZ/l/77/lA

The entire process (Steps 1and2) requires 1 millisecond


TABLE 1-2 (msec); depolarization (Step 1) takes 0.3 msec; repolariza­
Intracellular and Extracellular Ionic Concentrations tion (Step 2) takes 0.7 msec.
Intracellular, Extracellular, Ratio
Ion mEq/L mEq/L (approximate)
Potassium 110-170 3-5 27:1 Electrochemistry of Nerve Conduction
(IC') The precedingsequenceof eventsdepends on two important
Sodium 5-10 140 1:14 factors: the concentrations of electrolytes in the axoplasm
(Na+) (interior of the nerve cell) and extracellularfluids, and the
Chloride 5-10 110 1: 11 permeability of the nerve membrane to sodium and potas­
(Ci-)
sium ions.
Table 1-2 shows the differing concentrations of ions
found within neurons and in the extracellularfluids.Signifi­
(see Fig. 1-7, Step lC). The interior of the nerve is now cant differencesexistfor ions between their intracellular and
electricallypositive in relation to the exterior.An extracellular concentrations. These ionic gradients differ
electricalpotential of +40 mV exists on the interior of because the nerve membrane exhibits selectivepermeability.
the nerve cell."
Resting State. In its resting state, the nerve membrane is
Step 2. After these steps of depolarization, repolarization • Slightlypermeable to sodium ions (Na")
occurs (Fig. 1-7, Step 2). The electrical potential gradually • Freelypermeable to potassium ions (K+)
becomes more negative inside the nerve cell relative to • Freelypermeable to chloride ions (Ci-)
outside until the original resting potential of - 70 mV is Potassiumremains within the axoplasm,despiteits ability
again achieved. to diffuse freely through the nerve membrane and its

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8 PARTI The Drugs

concentration gradient (passive diffusion usually occurs its concentration gradient (higher ~ lower). After the
from a region of greater concentration to one of lesser con­ return of the membrane potential to its original level
centration), because the negative charge of the nerve mem­ (-70 mV), a slight excess of sodium exists within the nerve
brane restrains the positively charged ions by electrostatic cell, along with a slight excess of potassium extracellularly.
attraction. A period of metabolic activity then begins in which active
Chloride remains outside the nerve membrane instead of transfer of sodium ions out of the cell occurs via the
moving along its concentration gradient into the nerve cell, sodium pump. An expenditure of energy is necessary to
because the opposing, nearly equal, electrostatic influence move sodium ions out of the nerve cell against their con­
(electrostatic gradient from inside to outside) forces outward centration gradient; this energy comes from the oxidative
migration. The net result is no diffusion of chloride through metabolism of adenosine triphosphate (ATP). The same
the membrane. pumping mechanism is thought to be responsible for
Sodium migrates inwardly because both the concentra­ the active transport of potassium ions into the cell against
tion (greater outside) and the electrostatic gradient (positive their concentration gradient. The process of repolarization
ion attracted by negative intracellular potential) favor such requires 0.7 msec.
migration. Only the fact that the resting nerve membrane is Immediately after a stimulus has initiated an action
relatively impermeable to sodium prevents a massive influx potential, a nerve is unable, for a time, to respond to
of this ion. another stimulus regardless of its strength. This is termed
the absolute refractory period, and it lasts for about the
duration of the main part of the action potential. The abso­
Membrane Excitation lute refractory period is followed by a relative refractory
Depolarization. Excitation of a nerve segment leads to period, during which a new impulse can be initiated but
an increase in permeability of the cell membrane to sodium only by a stronger than normal stimulus. The relative refrac­
ions. This is accomplished by a transient widening of trans­ tory period continues to decrease until the normal level of
membrane ion channels sufficient to permit the unhindered excitability returns, at which point the nerve is said to be
passage of hydrated sodium ions. The rapid influx of sodium repolarized.
ions to the interior of the nerve cell causes depolarization of During depolarization, a major proportion of ionic
the nerve membrane from its resting level to its firing thresh­ sodium channels are found in their open (O) state (thus
old of approximately-SO to -60 mV (see Fig. 1-7, Steps lA permitting the rapid influx of Na"), This is followed by a
and lB).12 The firing threshold is actually the magnitude of slower decline into a state of inactivation (I) of the channels
the decrease in negative transmembrane potential that is to a nonconducting state. Inactivation temporarily converts
necessary to initiate an action potential (impulse). the channels to a state from which they cannot open in
A decrease in negative transmembrane potential of 15 mV response to depolarization (absolute refractory period). This
(e.g., from -70 to -55 mV) is necessary to reach the firing inactivated state is slowly converted back, so that most chan­
threshold; a voltage difference of less than 15 mV will not nels are found in their closed (C) resting form when the
initiate an impulse. In a normal nerve, the firing threshold membrane is repolarized (-70 mV). Upon depolarization,
remains constant. Exposure of the nerve to a local anesthetic the channels change configuration, first to an open ion­
raises its firing threshold. Elevating the firing threshold conducting (O) state and then to an inactive nonconducting
means that more sodium must pass through the membrane (I) state. Although both C and I states correspond to non­
to decrease the negative transmembrane potential to a level conducting channels, they differ in that depolarization can
where depolarization occurs. recruit channels to the conducting 0 state from C but not
When the firing threshold is reached, membrane perme­ from I. Figure 1-8 describes the sodium channel transition
ability to sodium increases dramatically and sodium ions stages.13
rapidly enter the a.xoplasm. At the end of depolarization (the
peak of the action potential), the electrical potential of the Membrane Channels. Discrete aqueous pores through the
nerve is actually reversed; an electrical potential of +40 mV excitable nerve membrane, called sodium (or ion) channels,
exists (see Fig. 1-7, Step IC). The entire depolarization are molecular structures that mediate its sodium permeabil­
process requires approximately 0.3 msec. ity. A channel appears to be a lipoglycoprotein firmly situ­
Repolarization. The action potential is terminated when ated in the membrane (see Fig. 1-4). It consists of an aqueous
the membrane repolarizes. This is caused by the extinction pore spanning the membrane that is narrow enough at least
(inactivation) of increased permeability to sodium. In many at one point to discriminate between sodium ions and
cells, permeability to potassium also increases, resulting in others; Na+passes through 12 times more easily than K+.The
the efflux of K', and leading to more rapid membrane repo­ channel also includes a portion that changes configuration
larization and return to its resting potential (see Fig. 1-7, in response to changes in membrane potential, thereby
Step 2). gating the passage of ions through the pore (C, 0, and I states
Movement of sodium ions into the cell during depolar­ are described). The presence of these channels helps explain
ization and subsequent movement of potassium ions out membrane permeability or impermeability to certain ions.
of the cell during repolarization are passive (not requiring Sodium channels have an internal diameter of approximately
the expenditure of energy), because each ion moves along 0.3 x 0.5 nm.14

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CHAPTER1 Neurophysiology 9

Closed Open Inactive


Extracel~ Depolarized
side

++

Cytoplasmic
side

Figure 1-8. Sodium channel transition stages.Depolarization reversesresting membrane potential from interior negative (left) to interior
positive (center). The channel proteins undergo corresponding conformational changes from resting state (closed) to ion-conducting stage
(open). State changescontinue from open (center) to inactive (right), where channel configuration assumesa different,but still impermeable,
state. With repolarization, the inactivated refractory channel reverts to the initial resting configuration (left), ready for the next sequence.
(Redrawn from Siegelbaum SA, Koester F: Ion channels. In Kandel ER, editor: Principles of neural science, ed 3, Norwalk, Conn, 1991,
Appleton-Lange.)

A sodium ion is thinner than a potassium or chloride ion


Extracellularfluid
and therefore should diffuse freely down its concentration
gradient through membrane channels into the nerve cell.
However,this does not occur, because all these ions attract
water molecules and thus become hydrated. Hydrated
sodium ions have a radius of 3.4 .A, which is approximately
50% greater than the 2.2 .A radius of potassium and chloride
0
ions. Sodium ions therefore are too large to pass through
narrow channelswhen a nerve is at rest (Fig.1-9).Potassium

11°1 i l l l
and chloride ions can pass through these channels. During
depolarization, sodium ions readily pass through the nerve
membrane because configurational changes that develop
within the membrane produce transient widening of these
0
transmembrane channels to a size adequate to allow the ::J :::I 0 ::J
unhindered passage of sodium ions down their concentra­
tion gradient into the axoplasm (transformation from the
C to the 0 configuration). This concept can be visualized
as the opening of a gate during depolarization that is par­
tially occluding the channel in the resting membrane (C)
(Fig. 1-10). Axoplasm
Evidenceindicates that channel specificityexists in that
sodium channels differfrom potassium channels.15The gates Figure 1-9. Membrane channels are partially occluded; the
on the sodium channel are located near the external surface nerve is at rest. Hydrated sodium ions (Na") are too large to pass
of the nerve membrane, whereas those on the potassium through channels, although potassium ions (K') can pass through
unimpeded.
channel are located near the internal surface of the nerve
membrane.
The stimulus disrupts the resting equilibrium of the nerve
Impulse Propagation membrane; the transmembrane potential is reversed
After initiation of an action potential by a stimulus, the momentarily, with the interior of the cell changing from
impulse must move alongthe surfaceof the axon.Energyfor negativeto positive,and the exterior changing from positive
impulse propagation is derivedfrom the nerve membrane in to negative.This new electrical equilibrium in this segment
the followingmanner. of nerve produces local currents that begin to fl.owbetween

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10 PART I The Drugs

Impulse

Extracellularfluid

@ Impulse

E:)
.I
j ! I.
l ! l
::J
j

::J Myelin_)
Figure 1-11. Saltatory propagation. Comparison of impulse
propagation in nonmyelinated (upper) and myelinated (lower)
axons. In nonmyelinated axons, the impulse moves forward by
sequential depolarization of short adjoining membrane segments.
Axoplasm Depolarization in myelinated axons, on the other hand, is discon­
tinuous; the impulse leaps forward from node to node. Note how
much farther ahead the impulse is in the myelinatedaxon after four
Figure 1-1O. Membrane channels are open; depolarization
depolarization sequences.(Redrawnfrom de Jong RH: Localanes­
occurs. Hydrated sodium ions (Na") now pass unimpeded through
thetics, St Louis, 1994,Mosby.)
the sodium channel.

the depolarizedsegment and the adjacent resting area. These in the density of current within a short distance of the depo­
local currents flow from positive to negative, extending for larized segment.In areas immediatelyadjacent to this depo­
severalmillimeters along the nerve membrane. larized segment, local current flow may be adequate to
Asa result of this current flow,the interior of the adjacent initiate depolarization in the resting membrane. Farther
area becomes less negative and its exterior less positive. away it will prove to be inadequate to achieve a firing
Transmembrane potential decreases, approaching firing threshold.
threshold for depolarization. When transmembrane poten­ The spread of an impulse in an unmyelinated nerve fiber
tial is decreased by 15 mV from resting potential, a firing therefore is characterized as a relatively slow forward­
threshold is reached and rapid depolarization occurs. The creeping process (Fig. 1-11). The conduction rate in unmy­
newlydepolarizedsegment sets up local currents in adjacent elinated C fibers is 1.2 m/sec compared with 14.8to 120ml
resting membrane, and the entire process starts anew. sec in myelinatedA-alpha and A-delta fibers.16
Conditions in the segment that has just depolarized
return to normal after the absolute and relative refractory Myelinated Nerves. Impulse spread within myelinated
periods. Because of this, the wave of depolarization can nerves differs from that in unmyelinated nerves because of
spread in only one direction. Backward (retrograde) move­ the layer of insulating material separating the intracellular
ment is prevented by the inexcitable,refractory segment. and extracellularcharges.The farther apart are the charges,
the smalleris the current necessaryto chargethe membrane.
Impulse Spread Localcurrents thus can travel much farther in a myelinated
The propagated impulse travels along the nerve membrane nerve than in an unmyelinated nerve before becoming inca­
toward the CNS.The spread of this impulse differs depend­ pable of depolarizing the nerve membrane ahead of it.
ing on whether or not a nerve is myelinated. Impulse conduction in myelinated nerves occurs by
means of current leaps from node to node, a processtermed
Unmyelinated Nerves. An unmyelinatednerve fiberis basi­ saltatory conduction (see Fig. 1-11) (saltare is the Latin
cally a long cylinder with a high-electrical resistance cell verb "to leap"). This form of impulse conduction proves to
membrane surrounding a low-resistanceconducting core of be much fasterand more energyefficientthan that employed
axoplasm,all of which is bathed in low-resistanceextracel­ in unmyelinated nerves. The thickness of the myelin
lular fluid. sheath increases with increasing diameter of the axon. In
The high-resistance cell membrane and low-resistance addition, the distance between adjacent nodes of Ranvier
intracellularand extracellularmedia produce a rapid decrease increases with greater axonal diameter. Because of these

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CHAPTER 1 Neurophysiology 11

two factors, saltatory conduction is more rapid in a thicker because some of the local anesthetic moleculescarried a net
axon. positive charge, they made the electrical potential at the
Saltatory conduction usually progresses from one node to membrane surface more positive,thus decreasingthe excit­
the next in a stepwise manner. However, it can be demon­ ability of the nerve by increasing the threshold potential.
strated that the current flow at the next node still exceeds Current evidence indicates that the resting potential of the
that necessary to reach the firing threshold of the nodal nerve membrane is unaltered by local anesthetics (they do
membrane. If conduction of an impulse is blocked at one not become hyperpolarized), and that conventional local
node, the local current skips over that node and proves ade­ anestheticsact within membrane channels rather than at the
quate to raise the membrane potential at the next node to its membrane surface. Also, the surface charge theory cannot
firing potential, producing depolarization. A minimum of explain the activity of uncharged anesthetic molecules in
perhaps 8 to 10 mm of nerve must be covered by anesthetic blocking nerve impulses (e.g.,benzocaine).
solution to ensure thorough blockade.17 Two other theories, membrane expansion and specific
receptor, are given credence today. Of the two, the specific
receptor theory is more widely held.
MODE AND SITE OF ACTION OF
The membrane expansion theory states that local anes­
LOCAL ANESTHETICS
thetic molecules diffuse to hydrophobic regions of excitable
How and where local anesthetics alter the processes of membranes, producing a general disturbance of the bulk
impulse generation and transmission needs to be discussed. membrane structure, expanding some critical region(s) in
It is possiblefor localanestheticsto interferewith the excita­ the membrane, and preventing an increase in permeability
tion process in a nerve membrane in one or more of the to sodium ions.22.23 Local anesthetics that are highly lipid
followingways: soluble can easily penetrate the lipid portion of the cell
1. Altering the basic resting potential of the nerve membrane, producing a changein configuration of the lipo­
membrane protein matrix of the nerve membrane. This results in a
2. Altering the threshold potential (firing level) decreaseddiameter of sodium channels,which leadsto inhi­
3. Decreasingthe rate of depolarization bition of both sodium conductance and neural excitation
4. Prolonging the rate of repolarization (Fig. 1-12). The membrane expansion theory serves as a
It has been established that the primary effects of local possible explanation for the local anesthetic activity of a
anesthetics occur during the depolarization phase of the drug such as benzocaine, which does not exist in cationic
action potential.18 These effectsinclude a decreasein the rate form yet still exhibitspotent topical anesthetic activity.It has
of depolarization, particularly in the phase of slow depolar­ been demonstrated that nerve membranes,in fact,do expand
ization. Becauseof this, cellular depolarization is not suffi­ and become more fluid when exposed to local anesthetics.
cient to reduce the membrane potential of a nerve fiber to However,no direct evidencesuggeststhat nerve conduction
its firing level, and a propagated action potential does not is entirely blocked by membrane expansion per se.
develop. There is no accompanying change in the rate of The specific receptor theory, the most favored today, pro­
repolarization. poses that local anesthetics act by binding to specificrecep­
tors on the sodium channel (Fig. 1-13).24 The action of the
Where Do Local Anesthetics Work? drug is direct, not mediated by some change in the general
The nerve membrane is the site at which local anesthetics properties of the cellmembrane. Both biochemicaland elec­
exert their pharmacologic actions. Many theories have been trophysiologicstudies have indicated that a specificreceptor
promulgated over the years to explain the mechanism of site for local anesthetics exists in the sodium channel either
action of local anesthetics, including the acetylcholine, on its external surface or on the internal axoplasmic
calcium displacement,and surface charge theories. The ace­ surface.25'26 Once the local anesthetic has gained accessto the
tylcholine theory stated that acetylcholine was involved in receptors,permeabilityto sodium ions is decreasedor elimi­
nerve conduction, in addition to its role as a neurotransmit­ nated, and nerve conduction is interrupted.
ter at nerve synapses.19No evidenceindicatesthat acetylcho­ Local anesthetics are classifiedby their ability to react
line is involvedin neural transmission along the body of the with specificreceptor sitesin the sodium channel. It appears
neuron. The calcium displacement theory, once popular, that drugs can alter nerve conduction in at least four sites
maintained that local anesthetic nerve block was produced within the sodium channel (see Fig. 1-13):
by the displacement of calcium from some membrane site 1. Within the sodium channel (tertiary amine local
that controlled permeability to sodium.20 Evidence that anesthetics)
varying the concentration of calcium ions bathing a nerve 2. At the outer surface of the sodium channel
does not affect local anesthetic potency has diminished the (tetrodotoxin, saxitoxin)
credibility of this theory. The surface charge (repulsion) 3 and 4. At the activation or the inactivation gate (scorpion
theory proposed that local anesthetics act by binding to the venom)
nerve membrane and changingthe electricalpotential at the Table 1-3 is a biological classificationof local anesthetics
membrane surface.21 Cationic (RNW) (p. 16) drug mole­ based on their site of action and the active form of the
cules were aligned at the membrane-water interface, and compound. Drugs in Class C exist only in the uncharged

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12 PART I The Drugs

/
.... --- ....•.•. ,
,
/
' \
I

Benzocalne
\\ (RN) \ ,
''
'... ... _ ,' ,,
Extracellular Extracellular

Intracellular Intracellular

Figure 1·12. Membrane expansion theory.

TABLE 1-3
Classification of LocalAnesthetic SubstancesAccording to Biological Site and Mode of Action
Classification Definition Chemical Substance
ClassA Agents acting at receptor site on external surface of nerve Biotoxins (e.g.,tetrodotoxin, saxitoxin)
membrane
ClassB Agents acting at receptor site on internal surface of nerve Quaternary ammonium analogs of lidocaine
membrane Scorpion venom
Class C Agents acting by a receptor-independent physico-chemical Benrocaine
mechanism
ClassD Agents acting by combination of receptor and receptor­ Most clinicallyuseful local anesthetic agents (e.g., articaine,
independent mechanisms lidocaine, mepivacaine,prilocaine)
Modified from Covino BG, Vassallo HG: Local anesthetics: mechanisms of action and clinical use, New York, 1976, Grune & Stratton. Used by permission.

form (RN), whereas Class D drugs exist in both charged only site at which molecules of local anesthetic have access
and uncharged forms. Approximately 90% of the blocking to the nerve membrane is at the nodes of Ranvier, where
effects of Class D drugs are caused by the cationic form of sodium channels are found in abundance. Ionic changes
the drug; only 10% of blocking action is produced by the that develop during impulse conduction arise only at the
base (Fig. 1-14). nodes.
Because an impulse may skip over or bypass one or two
Myelinated Nerve Fibers. One additional factor should blocked nodes and continue on its way, it is necessary for at
be considered with regard to the site of action of local least two or three nodes immediately adjacent to the anes­
anesthetics in myelinated nerves. The myelin sheath insu­ thetic solution to be blocked to ensure effective anesthesia-a
lates the axon both electrically and pharmacologically. The length of approximately 8 to 10 mm.

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CHAPTER1 Neurophysiology 13

9•
(sodium channel)

Local anesthetic JI Benzocalne

\1 R-LA
Udocalne,
""""-... prllocalne,
"meplvacalne,
artlcalne,
buplvacaine

Axoplasm
Centruroides / "" Lelrus scorpion venom,
scorpion venom sea anemone venom

Figure 1-13. A, Tertiary amine local anesthetics inhibit the influx of sodium during nerve conduction by binding to a receptor within
the sodium channel (R-LA).This blocks the normal activation mechanism (O gate configuration, depolarization) and also promotes move­
ment of the activation and inactivation gates (m and h) to a position resembling that in the inactivated state (I). B, Biotoxins (R-T) block
the influx of sodium at an outer surface receptor; various venoms do it by altering the activity of the activation and inactivation gates;and
benzocaine (R-B)does it by expanding the membrane. C, Channel in the closed configuration. (Redrawn from PallaschTJ: Dent Drug Serv
Newsletter4:25, 1983.)

Open Closed Plugged

Figure 1-14. Channel entry. On the left is an open channel, inward permeant to sodium ion. The center channel is in the resting closed
configuration;although impermeant to sodium ion here, the channel remains voltageresponsive.The channel on the right, although in open
configuration, is impermeant because it has local anesthetic cation bound to the gating receptor site. Note that local anesthetic enters the
channel from the axoplasmic (lower) side; the channel filter precludes direct entry via the external mouth. Local anesthetic renders the
membrane impermeant to sodium ion, hence inexcitableby local action currents. (Redrawn from de Jong RH: Local anesthetics, St Louis,
1994,Mosby.)

Sodium channel densities differ in myelinated and nerve membranes. For example, in the garfish olfactory
urunyelinated nerves. In small unmyelinated nerves, the nerve, the ratio of sodium channels to phospholipid
density of sodium channels is about 35/µm, whereas at molecules is 1:60,000, corresponding to a mean distance
the nodes of Ranvier in myelinated fibers, it may be as between channels of 0.2 µm, whereas at densely packed
high as 20,000/µm. On an averagenerve length basis, rela­ nodes of Ranvier, the channels are separated by only
tively few sodium channels are present in unmyelinated 70 A.21,2s

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14 PARTI The Drugs

How Local Anesthetics Work Lipophilic : Intermediate Hydrophilic


The primary action of local anesthetics in producing a con­ part i chain ~rt
duction block is to decrease the permeability of ion channels
to sodium ions (Na"), Local anesthetics selectively inhibit the
peak permeability of sodium, whose value is normally about
A
Qt- 0000 N

five to six times greater than the minimum necessary for


impulse conduction (e.g., there is a safety factor for conduc­
i
' ':
" R2
: /
tion of 5x to 6x). 29 Local anesthetics reduce this safety factor,
decreasing both the rate of rise of the action potential and
R
Ot '
COOR
1
i:
'
N

Ra
i '
I : '

its conduction velocity. When the safety factor falls below B


unity, 10 conduction fails and nerve block occurs.
Local anesthetics produce a very slight, virtually insignifi­ ! /Ra
R ' NHCO-R2-N
cant decrease in potassium (K') conductance through the
'\,R4
nerve membrane.
Calcium ions (Ca"), which exist in bound form within
c
the cell membrane, are thought to exert a regulatory role on Figure 1-15. A, Typical local anesthetic. B, Ester type. C, Amide
the movement of sodium ions across the nerve membrane. type.
Release of bound calcium ions from the ion channel receptor
site may be the primary factor responsible for increased and 1-16. The lipophilic part is the largest portion of the
sodium permeability of the nerve membrane. This repre­ molecule. Aromatic in structure, it is derived from benzoic
sents the first step in nerve membrane depolarization. Local acid, aniline, or thiophene (articaine). All local anesthetics
anesthetic molecules may act through competitive antago­ are amphipathic, that is, they possess both lipophilic and
nism with calcium for some site on the nerve membrane. hydrophilic characteristics, generally at opposite ends of the
The following sequence is a proposed mechanism of molecule. The hydrophilic part is an amino derivative of
action of local anesthetics': ethyl alcohol or acetic acid. Local anesthetics without a
1. Displacement of calcium ions from the sodium channel hydrophilic part are not suited for injection but are good
receptor site, which permits ... topical anesthetics (e.g., benzocaine). The anesthetic struc­
2. Binding of the local anesthetic molecule to this receptor ture is completed by an intermediate hydrocarbon chain
site, which produces ... containing an ester or an amide linkage. Other chemicals,
3. Blockade of the sodium channel, and a ... especially histamine blockers and anticholinergics, share this
4. Decrease in sodium conductance, which leads to ... basic structure with local anesthetics and commonly exhibit
5. Depression of the rate of electrical depolarization, weak local anesthetic properties.
and ... Local anesthetics may be classified as amino esters or
6. Failure to achieve the threshold potential level, along amino amides according to their chemical linkages. The
with ... nature of the linkage is important in defining several proper­
7. Lack of development of propagated action potentials, ties of the local anesthetic, including the basic mode of bio­
which is called ... transformation. Ester-linked local anesthetics (e.g., procaine)
8. Conduction blockade. are readily hydrolyzed in aqueous solution. Amide-linked
The mechanism whereby sodium ions gain entry to the local anesthetics (e.g., lidocaine) are relatively resistant to
axoplasm of the nerve, thereby initiating an action potential, hydrolysis. A greater percentage of an amide-linked drug
is altered by local anesthetics. The nerve membrane remains than of an ester-linked drug is excreted unchanged in the
in a polarized state because the ionic movements responsible urine. Procainamide, which is procaine with an amide
for the action potential fail to develop. Because the mem­ linkage replacing the ester linkage, is as potent a local anes­
brane's electrical potential remains unchanged, local cur­ thetic as procaine, yet because of its amide linkage, it is
rents do not develop, and the self-perpetuating mechanism hydrolyzed much more slowly. Procaine is hydrolyzed in
of impulse propagation is stalled. An impulse that arrives at plasma in only a few minutes, but just approximately 10%
a blocked nerve segment is stopped because it is unable to of procainamide is hydrolyzed in 1 day.
release the energy necessary for its continued propagation. As prepared in the laboratory, local anesthetics are basic
Nerve block produced by local anesthetics is called a nonde­ compounds that are poorly soluble in water and unstable on
polarizing nerve block. exposure to air," Their pl<. values range from 7.5 to 10. In
this form, they have little or no clinical value. However,
ACTIVE FORMS OF LOCAL ANESTHETICS because they are weakly basic, they combine readily with
acids to form local anesthetic salts, in which form they are
Local Anesthetic Molecules quite soluble in water and comparatively stable. Thus local
Most injectable local anesthetics are tertiary amines. Only a anesthetics used for injection are dispensed as acid salts,
few (e.g., prilocaine, hexylcaine) are secondary amines. The most commonly the hydrochloride salt (e.g., lidocaine HCl,
typical local anesthetic structure is shown in Figures 1-15 articaine HCl), dissolved in sterile water or saline.

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CHAPTER 1 Neurophysiology 15

Aromatic Intermediate Amino Aromatic Intermediate Amino


residue chain terminus residue chain terminus
ESTERS

Procaine Lidocaine

Propoxycaine Etidocaine
CH3 , CH
I
I
/ 3
NHCOCH-:-N
I ; "\
~ "-------1...__
CH3 : :
Tetracaine Mepivacaine

Benzocaine Prilocaine

Dyclonine•
*Dyclonlne ls a ketone.

Figure 1-16. Chemical configuration of local anesthetics. (From Yagiela JA, Neid.le EA, Dowd FJ: Pharmacology and therapeutics for
dentistry, ed 6, St Louis, 2010, Mosby.)

It is wellknown that the pH of a local anesthetic solution manufacturer to inhibit oxidation of the vasopressor (p. 18).
(as well as the pH of the tissue into which it is injected) The pH of solutions without epinephrine is about 6.5;
greatly influencesits nerve-blockingaction. Acidificationof epinephrine-containing solutions have a pH of about 3.5.
tissue decreases local anesthetic effectiveness.Inadequate Clinically,this lower pH is more likelyto produce a burning
anesthesia results when local anesthetics are injected into sensation on injection, as well as a slightly slower onset of
inflamed or infected areas. The inflammatory process pro­ anesthesia.
duces acidic products: The pH of normal tissue is 7.4; the Elevating the pH (alkalinization) of a local anesthetic
pH of an inflamed area is 5 to 6. Localanestheticscontaining solution speedsits onset of action, increasesits clinicaleffec­
epinephrine or other vasopressors are acidified by the tiveness,and makesits injection more comfortable.However,

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16 PART I The Drugs

the local anesthetic base, because it is unstable, precipitates


out of alkalinized solutions, making these preparations ill­ TABLE 1-4
suited for clinical use. Buffered (e.g., carbonated) local anes­ Dissociation Constants (pKJ of Local Anesthetics
thetics have received much attention in recent years both in Approximate
medicine and, more recently, in dentistry.31 Sodium bicar­ % Base (RN) Onset of
bonate or carbon dioxide (C02) added to the anesthetic Agent pK,, at pH 7.4 Action. min
solution immediately before injection provides greater Benzocaine 3.5 100
comfort and more rapid onset of anesthesia (see Chapter Mepivacaine 7.7 33 2-4
19).32•33The use of buffered local anesthetics in dentistry is Lidocaine 7.7 29 2-4
reviewedin depth in Chapter 20. Prilocaine 7.7 25 2-4
Despite potentially wide pH variation in extracellular Articaine 7.8 29 2-4
Etidocaine 7.9 25 2-4
fluids, the pH at the interior of a nerve remains stable.
Ropivacaine 8.1 17 2-4
Normal functioning of a nerve therefore is affectedverylittle Bupivacaine 8.1 17 5-8
by changes in the extracellular environment. However,the Tetracaine 8.6 7 10-15
ability of a local anesthetic to block nerve impulses is pro­ Cocaine 8.6 7
foundly altered by changes in extracellularpH. Chloroprocaine 8.7 6 6-12
Propoxycaine 8.9 4 9-14
Procaine 9.1 2 14-18
Dissociation of Local Anesthetics Procainamide 9.3
As discussed, local anesthetics are available as acid salts
(usuallyhydrochloride) for clinicaluse. The local anesthetic
salt, both water soluble and stable, is dissolved in sterile
water or saline. In this solution, it exists simultaneously as pH7.4
uncharged molecules (RN), also calledthe base, and as posi­ Extracellular
tivelycharged molecules (RNH+),called the cation. 750 250
ANH+ RN
RNH+~RN+H+
-=
The relativeproportion of each ionic form in the solution
varieswith the pH of the solution or surrounding tissues.In
the presence of a high concentration of hydrogen ions (low Nerve 8healh
pH), the equilibrium shifts to the left, and most of the anes­
thetic solution exists in cationic form: Intracellular
pH 7.4 RN~ ANH+
RNH+ >RN+H+ ANH+ RN 250
180 70
As hydrogenion concentration decreases(higherpH), the
equilibrium shifts toward the free base form:
Figure 1-17. Mechanism of action of the local anesthetic mol­
RNH+<RN+H+ ecule.Anesthetic pK. of 7.9;tissue pH of 7.4.

The relative proportion of ionic forms also depends on


the pK., or dissociation constant, of the specificlocal anes­ 1. One thousand molecules of a local anesthetic with a pK.
thetic. The pK. is a measure of the affinity of a molecule for of 7.9 are injected into the tissues outside a nerve. The
hydrogen ions (W). When the pH of the solution has the tissue pH is normal (7.4) (Fig. 1-17).
same value as the pK. of the local anesthetic, exactly50% of 2. From Table 1-4 and the Henderson-Hasselbalch
the drug existsin the RNW form and 50% in the RN form. equation, it can be determined that at normal tissue pH,
The percentage of drug existingin either form can be deter­ 75% of local anesthetic molecules are present in the
mined from the Henderson-Hasselbalchequation. cationic form (RNH+)and 25% in the free base form
Table 1-4 lists the pK. values for commonly used local (RN).
anesthetics. 3. In theory then, all 250 lipophilic RN moleculeswill
diffusethrough the nerve sheath to reach the interior
{axoplasm)of the neuron.
Actions on Nerve Membranes 4. When this happens, the extracellularequilibrium
The two factors involved in the action of a local anesthetic between RNW ~ RN has been disrupted by passageof
are (1) diffusion of the drug through the nerve sheath, and the free base forms into the neuron. The remaining 750
(2) binding at the receptor site in the ion channel. The extracellularRNH+moleculeswill now reequilibrate
uncharged, lipid-soluble, free base form (RN) of the anes­ accordingto the tissue pH and the pK. of the drugs:
thetic is responsible for diffusion through the nerve sheath.
This process is explained in the followingexample: RNH+{570)~ RN{l80)+ H+

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CHAPTER1 Neurophysiology 17

5. The 180 newly created lipophilic RN molecules diffuse


into the cell, starting the entire process (Step 4) again. pH6
Theoretically, this will continue until all local anesthetic Extracellular
molecules diffuse into the axoplasm. 990 10
The reality,however,is somewhat different. Not all the RNH+ RN
-
local anesthetic moleculeswill eventuallyreach the interior
of the nerve, because of the process of diffusion (drugs will
diffuse in all possible directions, not just toward the nerve),
Nerve sheath
and because some will be absorbed into blood vesselsand
extracellularsoft tissues at the injection site.
6. The inside of the nerve should be viewednext. After Intracellular
pH7.4 RN~ RNH+
penetration of the nerve sheath and entry into the RNH+ 10
RN
axoplasmby the lipophilic RN form of the anesthetic, 7.5 2.5
reequilibration takes place inside the nerve, because a
local anesthetic cannot exist in only the RN form at an
Figure 1-18. Effectof decreasedtissuepH on the actionsof a
intracellular pH of 7.4. Seventy-fivepercent of those RN localanesthetic.
molecules present within the axoplasm revert into the
RNH+form; the remaining 25% of molecules remain in
the uncharged RN form.
7. From the axoplasmicside, the RNH+ions enter into the and intracellular pH are highly significant in pain control
sodium channels,bind to the channel receptor site, and when inflammation or infection is present.34 The effectof a
ultimately are responsible for the conduction blockade decrease in tissue pH on the actions of a local anesthetic is
that results (see Figs. 1-13 and 1-14). described in Figure 1-18. This can be compared with the
Ofthetwofactors---diffusibilityandbinding-responsible example in Figure 1-17,involvingnormal tissue pH:
for local anesthetic effectiveness,the former is extremely 1. Approximately1000molecules of a local anesthetic with
important in actual practice.The ability of a local anesthetic a pK. of 7.9 are deposited outside a nerve. The tissue is
to diffusethrough the tissues surrounding a nerve is of criti­ inflamed and infected and has a pH of 6.
cal significance,because in clinicalsituations the local anes­ 2. At this tissue pH, approximately99% of local anesthetic
thetic cannot be applied directlyto the nerve membrane, as molecules are present in the charged cationic (RNW)
it can in a laboratory setting. Local anesthetic solutions form, with approximately 1% in the lipophilic free base
better able to diffuse through soft tissue provide an advan­ (RN) form.
tage in clinicalpractice. 3. Approximately10 RN molecules diffuse across the nerve
A local anesthetic with a high pK. value has very few sheath to reach the interior of the cell (contrasting with
moleculesavailablein the RN form at a tissue pH of 7.4.The 250 RN molecules in the healthy example). The pH of
onset of anesthetic action of this drug is slow because too the interior of the nerve cell remains normal (e.g.,7.4).
fewbase moleculesare availableto diffusethrough the nerve 4. Extracellularly,the equilibrium between RNH+~ RN,
membrane (e.g., procaine, with a pK. of 9.1). The rate of which has been disrupted, is reestablished.The relatively
onset of anesthetic action is related to the pK. of the local few newly created RN molecules diffuse into the cell,
anesthetic (see Table 1-4). starting the entire process again. However,a sum total
A local anesthetic with a lower pK. (<7.5) has a greater of fewer RN molecules succeed in eventuallycrossing
number of lipophilic free base moleculesavailableto diffuse the nerve sheath than would succeed at a normal pH
through the nerve sheath; however,the anesthetic action of because of greatly increased absorption of anesthetic
this drug is inadequate because at an intracellular pH of 7.4, molecules into the blood vesselsin the region (increased
only a very small number of base molecules dissociateback vascularity is noted in the area of inflammation and
to the cationic form necessary for binding at the receptor infection).
site. 5. After penetration of the nerve sheath by the base form,
In actual clinical situations with the local anesthetics reequilibrium occurs inside the nerve.Approximately
currently available,the pH of the extracellular fluid deter­ 75% of the molecules present intracellularlyrevert to
mines the easewith which a local anesthetic movesfrom the the cationic form (RNH+),25% remaining in the
site of its administration into the axoplasm of the nerve uncharged free base form (RN).
cell. The intracellular pH remains stable and independent 6. The cationic molecules bind to receptor siteswithin the
of the extracellularpH, because hydrogen ions (W), such as sodium channel, resulting in conduction blockade.
the local anesthetic cations (RNH+),do not readily diffuse Adequateblockadeof the nerveis more difficultto achieve
through tissues.The pH of extracellularfluid therefore may in inflamed or infectedtissuesbecause of the relativelysmall
differ from that of the nerve membrane. The ratio of anes­ number of molecules able to cross the nerve sheath (RN)
thetic cations to uncharged base molecules (RNH+/RN)also and the increased absorption of remaining anesthetic mol­
may vary greatly at these sites. Differencesin extracellular ecules into dilated blood vesselsin this region. Although it

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18 PARTI The Drugs

presents a potential problem in all aspectsof dental practice, the drug provides more RN form, thereby increasing the
this situation is seen most often in endodontics. Possible potency of the topical anesthetic; however,the drug in this
remedies are described in Chapter 16. form is more rapidly oxidized.The effectiveshelf life of the
local anesthetic is decreased as the pH of the drug is
Clinical Implications of pH and Local increased.30
Anesthetic Activity To enhance the clinical efficacyof topical anesthetics, a
Most commercially prepared solutions of local anesthetics more concentrated form of the drug is commonly used (5%
without a vasoconstrictor have a pH between 5.5 and 7. or 10% lidocaine) than for injection (2% lidocaine).
When injected into tissue, the vast buffering capacity Although only a small percentage of the drug is availablein
of tissue fluids returns the pH at the injection site to a the base form, raising the concentration provides additional
normal 7.4. Local anesthetic solutions containing a vaso­ RN molecules for diffusion and dissociation to the active
pressor (e.g.,epinephrine) are acidifiedby the manufacturer cation form at free nerve endings.
through the addition of sodium (meta)bisulfite to retard Some topical anesthetics (e.g., benzocaine) are not
oxidation of the vasoconstrictor, thereby prolonging the ionized in solution; thus their anesthetic effectivenessis
period of effectivenessof the drug. (See Chapter 3 for a unaffected by pH. Because of the poor water solubility of
discussionof the appropriate use of vasoconstrictorsin local benzocaine, its absorption from the site of application is
anesthetics.) minimal, and systemic reactions (e.g., overdose) are rarely
Epinephrine may be added to a local anesthetic solution encountered.
immediately before its administration without the addition
of antioxidants;however,if the solution is not used in a short KINETICS OF LOCAL ANESTHETIC ONSET AND
time, it will oxidize,slowlyturning yellowthen brown (much DURATION OF ACTION
like a slicedapple oxidizing).
Rapid oxidation of the vasopressor may be delayed, Barriers to Diffusion of the Solution
thereby increasingthe shelf life of the product, through the A peripheral nerve is composed of hundreds to thousands
addition of antioxidants.Sodium bisulfitein a concentration of tightly packed axons. These axons are protected, sup­
between 0.05% and 0.1% is commonly used. A 2% solution ported, and nourished by severallayersof fibrous and elastic
of lidocaine HCl, with a pH of 6.8, is acidifiedto 4.2 by the tissues. Nutrient blood vessels and lymphatics course
addition of sodium bisulfite. throughout the layers.
Evenin this situation, the enormous buffering capacityof Individual nerve fibers (axons) are coveredwith, and are
the tissues tends to maintain a normal tissue pH; however, separated from each other by, the endoneurium. The peri­
it does require a longer time to do so after injection of a pH neurium then binds these nerve fiberstogether into bundles
4.2 solution than with a pH 6.8 solution. During this time, calledfasciculi. The radial nerve, located in the wrist, con­
the local anesthetic is not ableto function at its full effective­ tains between 5 and 10 fasciculi. Each fasciculus contains
ness, resulting in a slower onset of clinical action for local between 500 and 1000individual nerve fibers.Fivethousand
anestheticswith vasoconstrictors compared with their plain nerve fibers occupy approximately 1 mm2 of space.
counterparts. The thickness of the perineurium varies with the
Localanestheticsare clinicallyeffectiveon both axonsand diameter of the fasciculusit surrounds. The thicker the peri­
free nerve endings. Free nerve endings lying below intact neurium, the slower the rate of local anesthetic diffusion
skin may be reached only by injection of anesthetic beneath across it.37 The innermost layer of perineurium is the peri­
the skin. Intact skin forms an impenetrable barrier to the lemma. It is coveredwith a smooth mesothelial membrane.
diffusion of local anesthetics. EMLA (eutectic mixture of The perilemma represents the main barrier to diffusion into
local anesthetics lidocaine and prilocaine) enables local a nerve.
anesthetics to penetrate intact skin, albeit slowly.35 Fasciculiare contained within a loose network of areolar
Mucous membranes and injured skin (e.g., burns, abra­ connective tissue called the epineurium. The epineurium
sions) lack the protection affordedby intact skin,permitting constitutes between 30% and 75% of the total cross-section
topicallyapplied localanestheticsto diffusethrough to reach of a nerve. Local anesthetics are readily able to diffuse
free nerve endings. Topical anesthetics can be employed through the epineurium because of its loose consistency.
effectivelywherever skin is no longer intact because of Nutrient blood vesselsand lymphatics traverse the epineu­
injury, as well as on mucous membranes (e.g., cornea, rium. These vessels absorb local anesthetic molecules,
gingiva,pharynx, trachea, larynx, esophagus,rectum, vagina, removing them from the site of injection.
bladder).36 The outer layerof the epineurium surrounding the nerve
The buffering capacity of mucous membrane is poor; is denser and is thickened, forming what is termed the epi­
thus topical application of a local anesthetic with a pH neural sheath or nerve sheath. The epineural sheath does not
between 5.5 and 6.5lowersthe regionalpH to below normal, constitute a barrier to diffusion of local anesthetic into a
and lesslocalanestheticbaseis formed. Diffusionof the drug nerve.
across the mucous membrane to free nerve endings is Table 1-5 summarizes the layers of a typical peripheral
limited, and nerve block is ineffective.Increasing the pH of nerve.

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CHAPTER 1 Neurophysiology 19

gradient. The greater the initial concentration of the local


Induction of Local Anesthesia anesthetic, the faster the diffusion of its molecules and the
Followingadministration of a local anesthetic into the soft more rapid its onset of action.
tissuesnear a nerve,moleculesof the localanesthetictraverse Fasciculithat are located near the surfaceof the nerve are
the distance from one site to another according to their termed mantle bundles (Fig.1-19,A). Mantle bundles are the
concentration gradient. During the induction phase of anes­ first ones reached by the local anesthetic and are exposedto
thesia, the local anesthetic moves from its extraneural site of a higher concentration of it. Mantle bundles usually are
deposition toward the nerve (as well as in all other possible blocked completely shortly after injection of a local anes­
directions). This process is termed diffusion. It is the unhin­ thetic (Fig. 1-19,B).
deredmigration of moleculesor ions through a fluid medium Fasciculifound closerto the center of the nerve are called
under the influence of the concentration gradient. Penetra­ core bundles. Corebundles are contacted by a localanesthetic
tion of an anatomic barrier to diffusion occurs when a drug only after much delay and by a lower anesthetic concentra­
passes through a tissue that tends to restrict free molecular tion because of the greater distance that the solution must
movement. The perineurium is the greatest barrier to pen­ traverse and the greater number of barriers it must cross.
etration of local anesthetics. As the local anesthetic diffusesinto the nerve, it becomes
increasinglydiluted bytissuefluidswith somebeing absorbed
Diffusion. The rate of diffusion is governed by several by capillaries and lymphatics. Ester anesthetics undergo
factors, the most significant of which is the concentration almost immediate enzymatichydrolysis.Thus core fibersare
exposed to a decreased concentration of local anesthetic, a
fact that may explain the clinical situation of inadequate
TABLE 1-5 pulpal anesthesia developing in the presence of subjective
Organization of a Peripheral Nerve symptoms of adequate soft tissue anesthesia.Complete con­
Structure Description duction blockade of all nerve fibers in a peripheral nerve
Nerve fiber Singlenerve cell requires that an adequate volume, as well as an adequate
Endoneurium Covers each nerve fiber concentration, of the local anesthetic be deposited. In no
Fasciculi Bundles of 500 to 1000nerve fibers clinical situation are 100%of the fibers within a peripheral
Perineurium* Covers fasciculi nerve blocked, even in cases of clinically excellent pain
Perilemma* Innermost layer of perineurium control.38 Fibersnear the surfaceof the nerve (mantle fibers)
Epineurium Alveolarconnective tissue supporting tend to innervate more proximal regions (e.g.,the molar area
fasciculiand carrying nutrient vessels with an inferior alveolarnerve block), whereas fibers in the
Epineural sheath Outer layer of epineurium core bundles innervate the more distal points of nerve dis­
*The perineurium and perilemma constitute the greatest anatomic tribution (e.g.,the incisorsand canine with an inferior alveo­
barriers to diffusion in a peripheral nerve. lar block).

Mantle Core fibers


bundles

I\
I\
I \
I \

----- Solution

::.:.:~Corebundles

Mantle fibers

- - - - - - - - Epineuralsheath

A B
Figure 1-19. A, Composition of nerve fibers and bundles within a peripheral nerve. B, In a large peripheral nerve (containing hundreds
or thousands of axons), local anesthetic solution must diffuse inward toward the nerve core from the extraneural site of injection. Local
anesthetic molecules are removed by tissue uptake while tissue fluid mixes with the carrier solvent.This results in gradual dilution of the
local anesthetic solution as it penetrates the nerve toward the core.A concentration gradient occurs during induction so that the outer mantle
fibers are solidly blocked, whereas the inner core fibers are not yet blocked. Not only are core fibers exposed to a lower local anesthetic
concentration, but the drug arrives later. Delay depends on the tissue mass to be penetrated and the diffusivity of the local anesthetic.
(Redrawn from B, de Jong RH: Local anesthetics,St Louis, 1994,Mosby.)

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20 PARTI The Drugs

Blocking Process. After deposition of local anesthetic as to attach more securelyto the protein receptor sites and to
close to the nerve as possible, the solution diffuses in all possessa longer duration of clinical activity,"
directions according to prevailing concentration gradients. Vasoactivity affects both the anesthetic potency and the
A portion of the injected local anesthetic diffusestoward the duration of anesthesiaprovided by a drug. Injection of local
nerve and into the nerve. However,a significant portion of anesthetics,such as procaine,with greatervasodilatingprop­
the injected drug also diffusesawayfrom the nerve.The fol­ erties increases perfusion of the local site with blood. The
lowing reactions then occur: injected local anesthetic is absorbed into the cardiovascular
1. Some of the drug is absorbed by nonneural tissues (e.g., compartment more rapidly and is carried away from the
muscle, fat). injection site and from the nerve,thus providing for a short­
2. Some is diluted by interstitial fluid. ened duration of anesthesia,as well as decreasedpotency of
3. Some is removed by capillariesand lymphatics from the the drug. Table 1-7 summarizes the influence of various
injection site. factors on local anesthetic action.
4. Ester-type anesthetics are hydrolyzed.
The sum total effectof these factorsis to decreasethe local Recovery from Local Anesthetic Block
anesthetic concentration outside the nerve; however, the Emergence from a local anesthetic nerve block followsthe
concentration of local anesthetic within the nerve continues same diffusion patterns as induction; however,it does so in
to rise as diffusionprogresses.Theseprocessescontinue until the reverseorder.
an equilibrium results between intraneural and extraneural The extraneural concentration of local anesthetic is con­
concentrations of anesthetic solution. tinually depleted by diffusion, dispersion, and uptake of the
drug, whereas the intraneural concentration of local anes­
Induction Time. Induction time is defined as the period thetic remains relativelystable. The concentration gradient
from deposition of the anesthetic solution to complete con­ is reversed,the intraneural concentration exceedsthe extra­
duction blockade. Severalfactors control the induction time neural concentration, and anesthetic molecules begin to
of a given drug. Those under the operator's control are the diffuse out of the nerve.
concentration of the drug and the pH of the local anesthetic Fasciculiin the mantle begin to lose the local anesthetic
solution. Factorsnot under the clinician'scontrol include the much sooner than do the core bundles. Local anesthetic
diffusion constant of the anesthetic drug and the anatomic within the core then diffusesinto the mantle, so that the first
diffusion barriers of the nerve. nerve fibers to entirely lose anesthesia are those centermost
in the nerve. Mantle fibers remain anesthetized the longest,
Physical Properties and Clinical Actions. Other physico­ and core fibers the shortest, time. Recoveryfrom anesthesia
chemicalfactors of a local anesthetic may influence its clini­ is a slower process than induction because the local anes­
cal characteristics. thetic is bound to the drug receptor site in the sodium
The effectof the dissociation constant (pK,.)on the rate of channel and therefore is released more slowly than it is
onset of anesthesia has been described. Although both absorbed.
molecular forms of the anesthetic are important in neural
blockade,drugs with a lower pK,.possessa more rapid onset Readministration of Local Anesthetic
of action than those with a higher pK,..39 Occasionally a dental procedure outlasts the duration of
Lipid solubility of a local anesthetic appears to be related clinically effective pain control, and a repeat injection of
to its intrinsic potency. The estimated lipid solubilities of local anesthetic is necessary. Usually this repeat injection
various local anesthetics are presented in Table 1-6. Greater immediately results in a return of profound anesthesia. On
lipid solubilitypermits the anesthetic to penetrate the nerve someoccasions,however,the clinicianmayencounter greater
membrane (which itself is 90% lipid) more easily.This is difficultyin reestablishing adequate pain control with sub­
reflectedbiologicallyin increased potency of the anesthetic. sequent injections.
Local anesthetics with greater lipid solubilityproduce more
effectiveconduction blockadeat lowerconcentrations (lower Recurrence of Immediate Profound Anesthesia. At the
percentage solutions or smaller volumes deposited) than is time of reinjection, the concentration of local anesthetic in
produced by less lipid-soluble local anesthetics. the core fibers is less than that in the mantle fibers.Partially
The degreeof protein binding of the local anesthetic mol­ recovered core fibers still contain some local anesthetic,
ecule is responsible for the duration of anesthetic activity. although not enough to provide complete anesthesia.After
Afterpenetration of the nerve sheath, a reequilibrium occurs deposition of a new high concentration of anesthetic near
between the base and cationic forms of the local anesthetic the nerve, the mantle fibers are once again exposed to a
according to the Henderson-Hasselbach equation. Now, in concentration gradient directed inward toward the nerve;
the sodium channel itself, RNH+ions bind at the receptor this eventually leads to an increased concentration in the
site. Proteins constitute approximately 10% of the nerve core fibers.This combination of residual local anesthetic (in
membrane, and local anesthetics (e.g., etidocaine, ropiva­ the nerve) and the newly deposited supply results in rapid
caine, bupivacaine) possessing a greater degree of protein onset of profound anesthesiaand administration of a smaller
binding (see Table 1-6) than others (e.g., procaine) appear volume of local anesthetic drug.

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CHAPTER 1 Neurophysiology 21

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22 PART I The Drugs

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S:s1..i< ll'l ..i< ll'l
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CHAPTER 1 Neurophysiology 23

TABLE 1-7
Factors Affecting Local Anesthetic Action
Factor Action Affected Description
pK. Onset LowerpK. = More rapid onset of action, more RN moleculespresent to diffuse through
nerve sheath; thus onset time is decreased
Lipid solubility Anesthetic potency Increased lipid solubility= Increased potency (e.g.,procaine= 1; etidocaine = 140)
Etidocaine produces conduction blockade at very low concentrations, whereas procaine
poorly suppressesnerve conduction, even at higher concentrations
Protein binding Duration Increased protein binding allowsanesthetic cations (RNH') to be more firmly attached to
proteins located at receptor sites;thus duration of action is increased
Nonnervous tissue Onset Increased diffusibility= Decreasedtime of onset
diffusibility
Vasodilatoractivity Anesthetic potency Greater vasodilator activity= Increased blood flow to region = Rapid removal of anesthetic
and duration molecules from injection site; thus anesthetic potency and duration are decreased
From Cohen S, Burns RC: Pathways of the pulp, ed 6, St Louis, 1994, Mosby.

Difficulty Reachieving Profound Anesthesia. In this to increased protein binding, other factors that influence the
second situation, as in the first, the dental procedure has rate of removal of a drug from the injection site are the
outlasted the clinical effectiveness of the local anesthetic vascularity of the injection site and the presence or absence
drug, and the patient is experiencing pain. The doctor read­ of a vasoactive substance. Anesthetic duration is increased in
ministers a volume of local anesthetic, but unlike in the first areas of decreased vascularity (e.g., Gow-Gates mandibular
scenario, effective control of pain does not occur. nerve block vs. inferior alveolar nerve block), and the addi­
Tachyphylaxis. In this second clinical situation, a process tion of a vasopressor decreases tissue perfusion to a local
known as tachyphylaxis occurs. Tachyphylaxis is defined as area, thus increasing the duration of the block.
increasing tolerance to a drug that is administered repeat­
edly. It is much more likely to develop if nerve function is
References
allowed to return before reinjection (e.g., if the patient com­
1. Covino BG, Vassallo HG: Local anesthetics: mechanisms of
plains of pain). The duration, intensity, and spread of anes­
action and clinical use, NewYork, 1976, Grune & Stratton.
thesia with reinjection are greatly reduced.41
2. Bennett CR: Monheim's local anesthesia and pain control in
Although difficult to explain, tachyphylaxis is probably dental practice, ed 5, St Louis, 1974, Mosby.
brought about by some or all of the following factors: edema, 3. Fitzgerald MJT: Neuroanatomy: basic and clinical, London,
localized hemorrhage, clot formation, transudation, hyper­ 1992, BailliereTyndall.
natremia, and decreased pH of tissues. The first four factors 4. Noback CR,StromingerNL,Demarest RJ:The human nervous
isolate the nerve from contact with the local anesthetic solu­ system: introduction and review, ed 4, Philadelphia, 1991,
tion. The fifth, hypernatremia, raises the sodium ion gradi­ Lea & Febiger.
ent, thus counteracting the decrease in sodium ion 5. SingerSJ,Nicholson GL:The fluid mosaic model of the struc­
conduction brought about by the local anesthetic. The last ture of cell membranes, Science 175:720--731, 1972.
factor, a decrease in pH of the tissues, is brought about by 6. Guyton AC:Basicneuroscience:anatomy and physiology,ed 2,
Philadelphia, 1991, WB Saunders.
the first injection of the acidic local anesthetic. The ambient
7. Guidotti G: The composition of biological membranes, Arch
pH in the area of injection may be somewhat lower, so that
Intern Med 129:194--201, 1972.
fewer local anesthetic molecules are transformed into the 8. Denson DD,Maziot JX:Physiology,pharmacology,and toxicity
free base (RN) on reinjection. of local anesthetics: adult and pediatric considerations. In
Raj PP, editor: Clinical practice of regional anesthesia, New
Duration of Anesthesia York, 1991, Churchill Livingstone.
As the local anesthetic is removed from the nerve, the func­ 9. Heavner JE: Molecular action of local anesthetics. In Raj PP,
tion of the nerve returns rapidly at first, but then it gradually editor: Clinicalpractice of regional anesthesia,NewYork,1991,
slows. Compared with onset of the nerve block, which is Churchill Livingstone.
rapid, recovery from the nerve block is much slower because 10. de Jong RH: Local anesthetics, ed 2, Springfield, Ill, 1977,
the local anesthetic is bound to the nerve membrane. Longer­ Charles C Thomas.
11. Hodgkin AL, HuxleyAF:A quantitative description of mem­
acting local anesthetics (e.g., bupivacaine, etidocaine, ropi­
brane current and its application to conduction and excitation
vacaine, tetracaine) are more firmly bound in the nerve
in nerve, J Physiol (London) 117:500--544, 1954.
membrane (increased protein binding) than are shorter­ 12. Noback CR, Demarest RJ: The human nervous system:basic
acting drugs (e.g., procaine, lidocaine) and therefore are principles of neurobiology,ed 3, NewYork,1981, McGraw-Hill,
released more slowly from receptor sites in the sodium chan­ pp 44--45.
nels. The rate at which an anesthetic is removed from a nerve 13. KeynesRD: Ion channels in the nerve-cellmembrane, SciAm
has an effect on the duration of neural blockade; in addition 240:326-335, 1979.

www.ShayanNemoodar.com
24 PARTI The Drugs

14. Cattarall WA:Structure and function of voltage-sensitiveion BollsL, editors: Ion channels in neural membranes, NewYork,
channels, Science242:50--61, 1988. 1986, Alan R Liss.
15. Hille B: Ionic selectivity, saturation, and block in sodium 29. Hille B, Courtney K, Dum R: Rate and site of action of local
channels: a four-barrier model, J Gen Physiol 66:535-560, anesthetics in myelinated nerve fibers. In Fink BR, editor:
1975. Molecular mechanisms of anesthesia, New York, 1975, Raven
16. Ritchie JM: Physiologicalbasis for conduction in myelinated Press,pp 13--20.
nerve fibers.In Morell P,editor: Myelin,ed 2, NewYork, 1984, 30. SetnikarI: Ionization of baseswith limited solubility:investiga­
Plenum Press,pp 117-145. tion of substances with local anesthetic activity,J Pharm Sci
17. Franz DN, Perry RS:Mechanismsfor differentialblock among 55:1190--1195, 1990.
single myelinated and non-myelinated axons by procaine, 31. Malamed SF: Buffering local anesthetics in dentistry, ADSA
J Physiol 235:193-210, 1974. Pulse 44(3):8--9, 2011.
18. de Jong RH,WagmanIH: Physiologicalmechanisms of periph­ 32. Stewart JH, Chinn SE, Cole GW, Klein JA: Neutralized lido­
eral nerve block by local anesthetics, Anesthesiology 24:684-- caine with epinephrine for local anesthesia-II,J Dermatol Surg
727, 1963. Oncol 16:942-945, 1990.
19. Dettbarn WD: The acetylcholine system in peripheral nerve, 33. BokeschPM,Raymond SA,Strichartz GR:Dependence oflido­
Ann NY Acad Sci 144:483-503, 1967. caine potency on pH and pC02• Anesth Analg 66:9-17, 1987.
20. Goldman DE, Blaustein MP: Ions, drugs and the axon mem­ 34. Bieter RN: Applied pharmacology of local anesthetics, Am J
brane, Ann NY Acad Sci 137:967-981, 1966. Surg 34:500--510, 1936.
21. Wei LY:Role of surface dipoles on axon membrane, Science 35. BuckleyMM, BenfieldP: Eutectic lidocaine/prilocaine cream:
163:280--282, 1969. a reviewof the topical anesthetic/analgesicefficacyof a eutectic
22. LeeAG:Model for action oflocal anesthetics,Nature 262:545- mixture of local anesthetics (EMLA),Drugs 46:126-151, 1993.
548, 1976. 36. CampbellAH, StasseJA,Lord GH, Willson JE:In vivo evalua­
23. Seeman P: The membrane actions of anestheticsand tranquil­ tion oflocal anestheticsapplied topically,J Pharm Sci 57:2045-
izers, Pharmacol Rev 24:583--655, 1972. 2048, 1968.
24. Strichartz GR, Ritchie JM: The action of local anesthetics on 37. Noback CR, Demarest RJ: The human nervous system:
ion channels of excitabletissues.In Strichartz GR,editor: Local basic principles of neurobiology, ed 3, New York, 1981,
anesthetics,NewYork, 1987, Springer-Verlag. McGraw-Hill.
25. Butterworth JF IY, Strichartz GR: Molecular mechanisms of 38. de Jong RH: Local anesthetics, ed 2, Springfield, Ill, 1977,
local anesthesia:a review,Anesthesiology72:711-734, 1990. Charles C Thomas, pp 66--68.
26. Ritchie JM: Mechanisms of action of local anesthetic agents 39. RitchieJM,RitchieB,GreengardP: The activestructure oflocal
and biotoxins, Br J Anaesth 47:191-198, 1975. anesthetics,J Pharmacol Exp Ther 150:152, 1965.
27. RasminskyM: Conduction in normal and pathological nerve 40. TuckerGT:Plasmabinding and disposition oflocal anesthetics,
fibers.In SwashM, Kennard C, editors: Scientificbasis of clini­ Int AnesthesiolClin 13:33, 1975.
cal neurology,Edinburgh, 1985, Churchill Livingstone. 41. Cohen EN, LevineDA,CollissJE,Gunther RE:The role of pH
28. Ritchie JM: The distribution of sodium and potassium chan­ in the development of tachyphylaxisto local anesthetic agents,
nels in mammalian myelinatednerve.In RitchieJM,KeyesRD, Anesthesiology29:994--1001, 1968.

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Pharmacology of Local
Anesthetics

Local anesthetics, when used for the management of pain, drug such as thiopental may produce arteriospasm with an
differ from most other drugs commonly used in medicine attendant decrease in tissue perfusion that if prolonged
and dentistry in one important manner. Virtually all other could lead to tissue death, gangrene,and loss of the affected
drugs, regardless of the route through which they are limb. In this situation, procaine is administered IA in an
administered, must ultimately enter into the circulatory attempt to break the arteriospasm and reestablishblood flow
systemin sufficientlyhigh concentrations (e.g.,attain thera­ to the affected limb. Tetracaine, chloroprocaine, and pro­
peutic blood levelsin their target organ[s]) before they can poxycaine also possess vasodilating properties to varying
begin to exert a clinical action. Local anesthetics, however, degreesbut not to the degree of procaine.
when used for pain control, cease to provide a clinicaleffect Cocaine is the only local anesthetic that consistently
when they are absorbed from the site of administration into produces vasoconstriction.4 The initial action of cocaine
the circulation.One prime factor involvedin the termination is vasodilation followedby an intense and prolonged vaso­
of action of local anesthetics used for pain control is their constriction. It is produced by inhibition of the uptake
redistribution from the nerve fiber into the cardiovascular of catecholamines (especially norepinephrine) into tissue
system. binding sites. This results in an excessof free norepineph­
The presence of a local anesthetic in the circulatory rine, leading to a prolonged and intense state of vasocon­
system means that the drug will be transported to every striction. This inhibition of the reuptake of norepinephrine
part of the body. Local anesthetics have the ability to alter has not been demonstrated with other local anesthetics,such
the functioning of some of these cells. In this chapter, the as lidocaine and bupivacaine.
actions of local anesthetics,other than their ability to block A significant clinical effect of vasodilation is an increase
conduction in nerve axonsof the peripheral nervous system, in the rate of absorption of the local anesthetic into the
are reviewed.A classificationof local anesthetics is shown in blood, thus decreasingthe duration and quality (e.g.,depth)
Box 2-1. of pain control, while increasing the anesthetic blood (or
plasma) concentration and its potential for overdose (toxic
PHARMACOKINETICS OF LOCAL ANESTHETICS reaction). The rates at which local anesthetics are absorbed
into the bloodstream and reach their peak blood level vary
Uptake according to the route of administration (Table2-2).
When injected into soft tissues,local anesthetics exert phar­
macologicaction on blood vesselsin the area.Alllocal anes­ Oral Route. With the exceptionof cocaine,local anesthetics
thetics possess a degree of vasoactivity, most producing are absorbed poorly, if at all, from the gastrointestinal tract
dilation of the vascular bed into which they are deposited, after oral administration. In addition, most local anesthetics
although the degreeof vasodilation may vary,and some may (especiallylidocaine) undergo a significanthepatic first-pass
produce vasoconstriction.To some degree,these effectsmay effectafter oral administration. Afterabsorption of lidocaine
be concentration dependent.1 Relativevasodilatingvalues of from the gastrointestinaltract into the enterohepatic circula­
amide local anesthetics are shown in Table2-1. tion, a fraction of the drug dose is carried to the liver,where
Ester local anesthetics are also potent vasodilating drugs. approximately72% of the dose is biotransformed into inac­
Procaine,the most potent vasodilator among local anesthet­ tive metabolites.5 This has seriously hampered the use of
ics, is occasionallyinjected clinicallyto induce vasodilation lidocaine as an oral antidysrhythmic drug. In 1984,Astra
when peripheral blood flowhas been compromised because Pharmaceuticals and Merck Sharp & Dohme introduced an
of (accidental) intra-arterial (IA) injection of a drug (e.g., analog of lidocaine,tocainide hydrochloride,which is effec­
thiopental)2 or injection of epinephrine or norepinephrine tive orally.6 The chemical structures of tocainide and lido­
into a fingertip or toe.3 IA administration of an irritating caine are presented in Figure 2-1.
25

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26 PARTI The Drugs

BOX 2-1 Classification of Local Anesthetics TABLE 2-2


Time to Achieve Peak Blood Level
Esters
Esters of benzoic acid Route Time, min
Butacaine Intravenous
Cocaine Topical 5 (approximately)
Ethyl aminobenzoate (benzocaine) Intramuscular 5-10
Hexylcaine Subcutaneous 30-90
Piperocaine
Tetracaine
Esters of para-aminobenzoic acid
Chloroprocaine
Procaine
Propoxycaine

Amides
Articaine
Bupivacaine
CH3
Dibucaine
Etidocaine
Lidocaine
Mepivacaine
Prilocaine
Q
B
CH3
NHCOCHCH3 • HCI
I
NH2

Ropivacaine
Figure 2-1. Tocainide. A, Represents a modification of lidocaine
(B) that is able to pass through the liver after oral administration
Quinoline with minimal hepatic first-pass effect.
Centbucridine

phageal or bladder mucosa, uptake is even slower than


TABLE 2-1 occurs through the pharynx. Wherever no layer of intact
Relative Vasodilating Values of Amide-Type skinis present,topicallyappliedlocalanestheticscan produce
Local Anesthetics an anesthetic effect. Sunburn remedies (e.g., Solarcaine,
MEAN % INCREASE IN Schering-PloughHealthCareProducts,Inc.,Memphis,Tenn)
FEMORAL ARTERY BLOOD usuallycontain lidocaine,benzocaine,or other anestheticsin
FLOW IN DOGS AFTER
an ointment formulation. Appliedto intact skin,they do not
Vasodilating INTRA-ARTERIAL INJECTION*
provide an anesthetic action, but with skin damaged by
Activity 1 min 5 min sunburn, they bring rapid relief of pain. A eutectic mixture
Articaine 1 (approx) NA NA of local anesthetics lidocaine and prilocaine (EMLA) has
Bupivacaine 2.5 45.4 30 been developedthat is able to provide surface anesthesia of
Etidocaine 2.5 44.3 26.6 intact skin.7
Lidocaine 1 25.8 7.5
Mepivacaine 0.8 35.7 9.5
Injection. The rate ofuptake (absorption) oflocal anesthet­
Prilocaine 0.5 42.1 6.3
Tetracaine NA 37.6 14
icsafter parenteral administration (subcutaneous,intramus­
cular,or N) is related to both the vascularityof the injection
Modified from Blair MR: Cardiovascularpharmacology of local site and the vasoactivityof the drug.
anaesthetics,Br J Anaesth 47(suppl):247-252,1975.
NA, Not available.
N administration of local anesthetics provides the most
*Eachagent injected rapidly at a dose of 1 mg/0.1 mL saline. rapid elevation of blood levelsand is used clinicallyin the
primary management of ventricular dysrhythmias.8 Rapid
N administration can lead to significantlyhigh local anes­
Topical Route. Local anesthetics are absorbed at differing thetic blood levels,which can induce serious toxic reactions.
rates after application to mucous membrane: In the tracheal The benefits to be accrued from N drug administration
mucosa, absorption is almost as rapid as with intravenous must alwaysbe carefullyweighedagainst any risks associated
(N) administration (indeed, intratracheal drug admini­ with N administration. Only when the benefits clearlyout­
stration [epinephrine, lidocaine, atropine, naloxone, and weigh the risks should the drug be administered, as is the
tlumazenil] is used in certain emergency situations); in the casewith pre-fatal ventricular dysrhythmias such as prema­
pharyngeal mucosa, absorption is slower; and in the eso- ture ventricular contractions (PVCs).9

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CHAPTER2 Pharmacology of LocalAnesthetics 27

one that is pharmacologicallyinactive.Metabolism (or bio­


Distribution transformation or detoxification) of local anesthetics is
Once absorbed into the blood, local anesthetics are distrib­ important because the overalltoxicity of a drug depends on
uted throughout the body to all tissues (Fig. 2-2). Highly a balance between its rate of absorption into the blood­
perfused organs (and areas), such as the brain, head, liver, stream at the site of injection and its rate of removal from
kidneys, lungs, and spleen, initially will have higher anes­
thetic blood levelsthan less highly perfused organs. Skeletal
muscle, although not as highly perfused as these areas, con­ TABLE 2-3
tains the greatest percentage of local anesthetic of any tissue Percentages of Cardiac Output Distributed to Different
or organ in the body because it constitutes the largest mass Organ Systems
of tissue in the body (Table 2-3). Percent of Cardiac
The plasma concentration of a local anesthetic in certain Region Output Received
target organs has a significantbearing on the potential toxic­ Kidney 22
ity of the drug. The blood level of the local anesthetic is Gastrointestinal system, spleen 21
influenced by the followingfactors: Skeletal muscle 15
1. Rate at which the drug is absorbed into the Brain 14
cardiovascularsystem Skin 6
2. Rate of distribution of the drug from the vascular Liver 6
compartment to the tissues (more rapid in healthy Bone 5
Heart muscle 3
patients than in those who are medicallycompromised
Other 8
[e.g.,congestiveheart failure],thus leading to lower
blood levelsin healthier patients) Adapted from Mohrman DE, Heller LJ: Cardiovascular physiology, ed 7,
New York, 2010, Lange Medical Books/McGraw-Hill.
3. Elimination of the drug through metabolic or excretory
pathways
The latter two factors serveto decreasethe blood levelof TABLE 2-4
the local anesthetic. Half-Life of Local Anesthetics
The rate at which a local anesthetic is removed from the
blood is described as its elimination half-life. Simply stated, Drug Half-life, hours
the elimination half-life is the time necessary for a 50% Chloroprocaine* 0.1
reduction in the blood level (one half-life= 50% reduction; Procaine* 0.1
two half-lives = 75% reduction; three half-lives = 87.5% Tetracaine* 0.3
Articainet 0.5
reduction; four half-lives= 94% reduction; five half-lives=
Cocaine* 0.7
97% reduction; sixhalf-lives= 98.5% reduction) (Table2-4).
Prilocainet 1.6
Alllocal anestheticsreadilycrossthe blood-brain barrier. Lidocainet 1.6
They also readilycrossthe placenta and enter the circulatory Mepivacainet 1.9
system of the developingfetus. Ropivacainet 1.9
Etidocainet 2.6
Metabolism (Biotransformation, Bupivacainet 3.5
Detoxification} Propoxycaine* NA
A significant difference between the two major groups of NA, Not available.
local anesthetics,the esters and the amides, is the means by *Ester.
which the body biologicallytransforms the active drug into tAmide.

Fat Slow
equilibrium
space
Muscle

Figure 2-2. Pattern of distribution of local anesthetics after


Brain absorption. (Redrawn from Wildsmith JAW, Armitage EN,
Myocardium Rapid McClure JH: Principles and practice of regional anesthesia,
SHa of ln)ecllon equilibrium ed 3, Edinburgh, 2003, Churchill Livingstone.)
Lungs space
Liver

Elimination

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28 PARTI The Drugs

Approximately 1 of every 2800 persons has an atypical


TABLE 2-5 form of pseudocholinesterase,which causes an inability to
Hydrolysis Rate of Esters hydrolyzeesterlocalanestheticsand other chemicallyrelated
Rate of Hydrolysis. drugs (e.g., succinylcholine).11Its presence leads to prolon­
Drug µmol/m Uhr gation of higher local anesthetic blood levelsand increased
Chloroprocaine 4.7 potential for toxicity.
Procaine 1.1 Succinylcholineis a short-acting muscle relaxant com­
Tetracaine 0.3 monly employed during the induction phase of general
anesthesia. It produces respiratory arrest (apnea) for a
period of approximately 2 to 3 minutes. Then plasma pseu­
docholinesterase hydrolyzes succinylcholine, blood levels

c
/~
Q fall, and spontaneous respiration resumes. Persons with
atypical pseudocholinesterase are unable to hydrolyze sue­
cinylcholineat a normal rate;thereforethe duration of apnea
is prolonged. Atypical pseudocholinesterase is a hereditary
OH trait. Any familial history of difficultyduring general anes­
thesia should be carefully evaluated by the doctor before
dental care commences.A confirmed or strongly suspected
Plasma history, in the patient or biological family,of atypical pseu­
PsChE docholinesterase represents a relative contraindication to
administration of ester-type local anesthetics.
There are absolute and relative contraindications to
OH
the administration of drugs. An absolute contraindication
I implies that under no circumstance should the drug in
CH2 question be administered to this patient because the possi­
I bility of potentially toxic or lethal reactions is increased,
CH2
I whereas a relative contraindication means that the drug in
/N"\. question may be administered to the patient after careful
C2Hs C2Hs weighing of the risk associatedwith use of the drug versus
Figure 2-3. Metabolic hydrolysis of procaine. PsChE, Pseudo­ the potential benefit to be gained, and if an acceptable
cholinesterase. (From Tucker GT: Biotransformation and toxicity alternative drug is not available. However, the smallest
of local anesthetics, Acta Anaesthesiol Belg 26[Suppl]: 123, 1975.) clinically effectivedose alwaysshould be used because the
likelihood of adverse reaction to this drug is increased in
this patient.
the blood through the processes of tissue uptake and
metabolism. Amide Local Anesthetics. The biotransformation of amide
local anesthetics is more complex than that of the esters.
Ester Local Anesthetics. Ester local anesthetics are hydro­ The primary site of biotransformation of amide local anes­
lyzed in the plasma by the enzyme pseudocholinesterase." thetics is the liver. Virtually the entire metabolic process
The rate at which hydrolysisof different esters occurs varies occurs in the liver for lidocaine, mepivacaine, etidocaine,
considerably (Table 2-5). and bupivacaine.Prilocaine undergoes primary metabolism
The rate of hydrolysis has an impact on the potential in the liver, with some also possibly occurring in the
toxicity* of a local anesthetic. Chloroprocaine, the most lung.12·13Articaine, a hybrid molecule containing both ester
rapidly hydrolyzed, is the least toxic, whereas tetracaine, and amide components, undergoes metabolism in both the
hydrolyzed 16 times more slowlythan chloroprocaine, has blood and the liver.14
the greatestpotential toxicity.Procaine undergoes hydrolysis The rates ofbiotransformation oflidocaine, mepivacaine,
to para-aminobenzoic acid (PABA), which is excreted etidocaine,and bupivacaineare similar.Thereforeliverfunc­
unchanged in the urine, and to diethylamine alcohol,which tion and hepatic perfusion significantlyinfluence the rate of
undergoes further biotransformation before excretion (Fig. biotransformation of an amide local anesthetic. Approxi­
2-3). Allergicreactions that occur in response to ester local mately 70% of a dose of injected lidocaine undergoes bio­
anesthetics usually are not related to the parent compound transformation in patients with normal liver function.5
(e.g.,procaine) but rather to PABA,which is a major meta­ Patients with lower than usual hepatic blood flow (hypo­
bolic product of many ester local anesthetics. tension, congestive heart failure) or poor liver function
(cirrhosis) are unable to biotransform amide local anes­
*All chemicals (drugs) have the potential to be poisons, also called toxins.
thetics at a normal rate.15•16 This slower than normal bio­
When the resulting blood level is too high, drugs exert negative actions, transformation rate results in higher anesthetic blood levels
which we call a toxic reaction or overdose. and increased risk of toxicity. Significant liver dysfunction

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CHAPTER 2 Pharmacology of LocalAnesthetics 29

(American Society of Anesthesiologists Physical Status clas­


sification system [ASA] 4 to 5) or heart failure (ASA 4 to 5) Excretion
represents a relative contraindication to the administration The kidneys are the primary excretory organ for both the
of amide local anesthetic drugs (Table 2-6). Articaine has local anesthetic and its metabolites.A percentage of a given
a shorter half-life than other amides (27 minutes vs. 90 dose of local anesthetic is excretedunchanged in the urine.
minutes) because a portion of its biotransformation occurs This percentage varies according to the drug. Esters appear
in the blood by the enzyme plasma cholinesterase.17 only in very small concentrations as the parent compound
The biotransformation products of certain local anes­ in the urine because they are hydrolyzedalmost completely
thetics can possess significant clinical activity if they are in the plasma. Procaine appears in the urine as PABA{90%)
permitted to accumulate in the blood. This may be seen in with 2% unchanged. Ten percent of a cocaine dose is found
renal or cardiac failure and during periods of prolonged in the urine unchanged. Amides usually are present in the
drug administration. A clinical example is the production urine as the parent compound in a greater percentage than
of methemoglobinemia in patients receiving large doses the esters,primarily because of their more complex process
of prilocaine.18•19 Prilocaine, the parent compound, does of biotransformation. Although the percentages of parent
not produce methemoglobinemia, but orthotoluidine, a drug found in urine vary from study to study, less than 3%
primary metabolite of prilocaine, does induce the forma­ lidocaine, 1% mepivacaine, and 1% etidocaine is found
tion of methemoglobin, which is responsible for methe­ unchanged in the urine.
moglobinemia. When methemoglobin blood levelsbecome Patients with significantrenal impairment may be unable
elevated,clinical signs and symptoms are observed. Methe­ to eliminate the parent local anesthetic compound or its
moglobinemiais discussedmore fullyin Chapter 10.Another major metabolites from the blood, resulting in slightlyele­
example of pharmacologically active metabolites is the vated blood levelsand therefore increased potential for tox­
sedativeeffect occasionallyobserved after lidocaine admin­ icity. This may occur with the esters or amides and is
istration. Lidocaine does not produce sedation; however, especiallylikelywith cocaine. Thus significant renal disease
two metabolites-monoethylglycinexylidide and glycine (ASA4 to 5) represents a relative contraindication to the
xylidide-are thought to be responsible for this clinical administration of local anesthetics. This includes patients
action." undergoing renal dialysisand those with chronic glomeru­
The metabolic pathways of lidocaine and prilocaine are lonephritis or pyelonephritis.
shown in Figures2-4 and 2-5.
SYSTEMIC ACTIONS OF LOCAL ANESTHETICS
Local anesthetics are chemicals that reversiblyblock action
TABLE 2-6 potentials in all excitable membranes. The central nervous
Lidocaine Disposition in Various Groups of Patients system(CNS)and the cardiovascularsystem(CVS)therefore
Mean Total are especiallysusceptible to their actions. Most of the sys­
Lidocaine Body Clearance. temic actions of local anesthetics are related to their blood
Group Half-Life, hr m Ukg/min or plasma levelin the target organ (CNS, CVS).The higher
Normal 1.8 10 the level,the greater will be the clinical action.
Heart failure 1.9 6.3 Centbucridine (a quinoline derivative) has proved to be
Hepatic disease 4.9 6 five to eight times as potent a local anesthetic as lidocaine,
Renal disease 1.3 13.7 with an equally rapid onset of action and an equivalent
Data from Thomson PD, et al: Lidocainepharmacokinetics in advanced
duration.i'r" Of potentially great importance is the finding
heart failure, liver disease,and renal failure in humans, Ann Intern Med that it does not adverselyaffect the CNS or CVS,except in
78:499-513, 1973. very high doses.

D DEVELOPMENT OF LOCAL ANESTHETIC AGENTS: TIMELINE


ESTERS
cocaine procaine tetracaine chloroprocaine
J.. J.. J.. J..
1884 1905 1932 1933 1948 1955 1956 1960 1963 1971 1975 1997 1999

AMIDES
t t t t t t t t t
dibucaine lidocaine mepivacaine prilocainebupivacaineetidocaine articaine ropivacainelevobupivacaine

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30 PARTI The Drugs

Conjugates

HO t .CH3
/C2H5
NH• CO• CH2N

tH3 " C2H5

3-Hydroxy-lidocaine (1.1)

Lidocaine
Monoethylglycinexylidide (3.7)

~ CH,~ \CH,

Conjugates_. _
~NH, ~NHCO•CH,NH,

CH3 CH3

2.6-Xylidide(1.0) Glycinexylidide(2.3)

Cooj- ~ HO~NH,
J, ~r ~NH,
CH~ 1

CH3 COOH
4-Hydroxy-2,6-dimethylaniline 2-Amino-3-methylbenzoicacid
(72.6)
Figure 2-4. Metabolic pathways of lidocaine. Percentages of dose found in urine are indicated in parentheses. (From Kennaghan JB,
BoyesRN: The tissue distribution, metabolism, and excretion of lidocaine in rats, guinea pigs, dogs and man, J Pharmacol Exp Ther Feb
180(2):454-463, 1972.)

Local anesthetics are absorbed from their site of admin­ existsa spectrum of other clinicalsigns and symptoms. (See
istration into the circulatorysystem,which effectivelydilutes Box 2-2, "Preconvulsive Signs and Symptoms of Central
them and carries them to all cellsof the body. The ensuing Nervous Toxicity.")
blood level of the local anesthetic depends on its rate of
uptake from the site of administration into the circulatory Anticonvulsant Properties. Some local anesthetics (e.g.,
system (increasingthe blood level),and on the rates of dis­ procaine, lidocaine, mepivacaine, prilocaine, even cocaine)
tribution in tissue and biotransformation (in the liver),pro­ have demonstrated anticonvulsant properties.P'" These
cessesthat remove the drug from the blood (decreasingthe occur at a blood level considerablybelow that at which the
blood level) (see Fig.2-2). same drugs produce seizure activity.Valuesfor anticonvul­
siveblood levelsoflidocaine are shown in Table2-7.25
Procaine, mepivacaine, and lidocaine have been used
Central Nervous System intravenouslyto terminate or decreasethe duration of both
Localanestheticsreadilycrossthe blood-brain barrier. Their grand mal and petit mal seizures.23'26 The anticonvulsant
pharmacologic action on the CNS is seen as depression.At blood level of lidocaine (about 0.5 to 4 µg/mL) is very
low (therapeutic, nontoxic) blood levels,no CNS effectsof close to its cardiotherapeutic range (see following). It has
any clinical significancehave been noted. At higher (toxic, been demonstrated to be effectivein temporarily arresting
overdose)levels,the primary clinicalmanifestation is a gen­ seizure activity in a majority of human epileptic patients.27
eralizedtonic-clonic convulsion.Betweenthesetwo extremes It was especiallyeffectivein interrupting status epilepticus

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CHAPTER2 Pharmacology of LocalAnesthetics 31

TABLE 2-7
Anticonvulsive Blood Levels of Lidocaine
Lidocaine Blood
Clinical Situation Level, µg/ml
Prilocaine (0.16)
Anticonvulsivelevel 0.5-4
Preseizuresigns and symptoms 4.5-7
Tonic-clonic seizure >7.5

CH3
at therapeutic doses of 2 to 3 mg/kg when given at a rate of
@- NH2 + HOOC • CH • N
I
/C3H7

CH3
"-H
40 to 50 mg/min.
Mechanism of Anticonvulsant Properties. Epileptic
patients possess hyperexcitable cortical neurons at a site
o-Toluidine n-Propylalanine within the brain where the convulsive episode originates
(0.69) (called the epileptic focus). Local anesthetics, by virtue of
t their depressant actions on the CNS,raisethe seizurethresh­

[@:~~l
old by decreasing the excitabilityof these neurons, thereby
preventing or terminating seizures.

Preconvulsive Signs and Symptoms. With a further


increasein the blood levelof the local anesthetic to aboveits
a<,1 \ a<,
therapeutic level,adversereactionsmaybe observed.Because
the CNSis much more susceptiblethan other systemsto the
HO-@-N~ ©(NH, actions oflocal anesthetics,it is not surprising that the initial
clinical signs and symptoms of overdose (toxicity) are CNS
in origin. With lidocaine, this second phase is observed at a
OH
levelbetween 4.5 and 7 µg/mLin the averagenormal healthy
4-Hydroxytoluidine 6-Hydroxytoluidine
(8.5) (6.5) patient.* Initial clinicalsigns and symptoms of CNStoxicity
are usually excitatoryin nature (see Box 2-2).
Figure 2-5. Metabolic pathways of prilocaine. Percentages of
dose found in urine are indicated in parentheses. All of these signs and symptoms, exceptfor the sensation
of circumoral and lingual numbness, are related to the direct
depressant action of the local anesthetic on the CNS.Numb­
ness of the tongue and circumoral regions is not caused by
CNS effectsof the local anesthetic.28 Rather it is the result of
a direct anesthetic action of the local anesthetic, which is
BOX 2-2 Preconvulsive Signs and Symptoms of present in high concentrations in these highly vascular
Central Nervous System Toxicity tissues,on free nerve endings.The anesthetic has been trans­
Signs (objectively Symptoms ported to these tissues by the CVS. A dentist treating a
observable) (subjectively felt) patient might have difficultyconceptualizingwhy anesthesia
Slurred speech Numbness of tongue of the tongue is considered to be a sign of a toxic reaction
Shivering and circumoral region when lingual anesthesia is commonly produced after man­
Muscular twitching Warm, flushed feelingof dibular nerve blocks. Consider for a moment a physician
Tremor of muscles of face skin administering a local anesthetic into the patient's foot.
and distal extremities Pleasant dreamlike state Overly high blood levelswould produce bilateral numbing
Generalizedlightheadedness of the tongue, as contrasted with the usual unilateral anes­
Dizziness thesia seen after dental nerve blocks.
Visual disturbances Lidocaineand procaine differ somewhat from other local
(inability to focus) anesthetics in that the usual progression of signs and symp­
Auditory disturbance toms just noted may not be seen. Lidocaine and procaine
(tinnitus) frequently produce an initial mild sedation or drowsiness
Drowsiness (more common with lidocaine).29 Becauseof this potential,
Disorientation
*Individual variation in response to drugs, as depicted in the normal dis­
tribution curve, may produce clinical symptoms at levelslower than these
(in hyperresponders) or may fail to produce them at higher levels (in
hyporesponders).

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32 PART I The Drugs

the U.S. Air Force and the U.S. Navy ground airplane pilots
TABLE 2-8
for 24 hours after receipt of a local anesthetic."
Sedation may develop in place of the excitatory signs. If
Effects of pC02 on the Convulsive Threshold {CD100) of
excitation or sedation is observed during the first 5 to 10
Various Local Anesthetics in Cats
minutes after intraoral administration of a local anesthetic, CD100. mg/kg Percent
it should serve as a warning to the clinician of a rising local pC02 pC02 Change
anesthetic blood level and the possibility (if the blood level Agent (25-40 torr) (6581 torr) in CD,oo
continues to rise) of a more serious reaction, including a Procaine 35 17 51
generalized convulsive episode. Mepivacaine 18 10 44
Prilocaine 22 12 45
Convulsive Phase. Further elevation of the local anesthetic Lidocaine 15 7 53
blood level leads to signs and symptoms consistent with a Bupivacaine 5 2.5 50
generalized tonic-donic convulsive episode. The duration of Data from EnglessonS, Grevsten S, Olin A: Some numerical methods
seizure activity is related to the local anesthetic blood level of estimating acid-basevariables in normal human blood with a
and is inversely related to the arterial partial pressure of haemoglobin concentration of 5 g/100 cm', Scand J Lab Clin Invest
carbon dioxide (pC02) level.31 At a normal pC02, a lidocaine 32:289-295, 1973.
blood level between 7.5 and 10 µg/mL usually results in a
convulsive episode. When carbon dioxide (C02) levels are
increased, the blood level of local anesthetic necessary for TABLE 2-9
seizures decreases while the duration of the seizure increases. 31 Convulsant Dose {CD100) and Acid-Base Status*
Seizure activity generally is self-limiting, because cardiovas­ pH 7.10 pH 7.20 pH 7.30 pH 7.40
cular activity usually is not significantly impaired, and redis­
pC02 30 27.5 26.6
tribution and biotransformation of the local anesthetic
pC0240 20.6 21.4 22.0
continue throughout the episode. This results in a decrease
pC02 60 13.1 15.4 17.5
in anesthetic blood level and termination of seizure activity, 11.3 14.3
pC02 80
usually within I minute.
However, several other mechanisms also at work unfor­ From EnglessonS:The influence of acid-base changes on central nervous
toxicity of local anaesthetic agents,ActaAnaesthesiolScand 18:88-103,
tunately act to prolong the convulsive episode. Both cerebral 1974.
blood flow and cerebral metabolism are increased during *Intravenouslidocaine 5 mg/kg/min, cats; doses in mg/kg.
local anesthetic-induced convulsions. Increased blood flow
to the brain leads to an increase in the volume of local
anesthetic being delivered to the brain, tending to prolong convulsions) through selective blockade of inhibitory path­
the seizure. Increased cerebral metabolism leads to a pro­ ways in the cerebral cortex.32-35 de Jong states that "inhibition
gressive metabolic acidosis as the seizure continues, and of inhibition thus is a presynaptic event that follows local
this tends to prolong the seizure activity (by lowering the anesthetic blockade of impulses traveling along inhibitory
blood level of anesthetic necessary to provoke a seizure), pathways."36
even in the presence of a declining local anesthetic level in The cerebral cortex has pathways of neurons that are
the blood. As noted in Tables 2-8 and 2-9, the dose of local essentially inhibitory and others that are facilitatory (excit­
anesthetic necessary to induce seizures is markedly dimin­ atory). A state of balance normally is maintained between
ished in the presence of hypercarbia (see Table 2-8) or the degrees of effect exerted by these neuronal paths (Fig.
acidosis (see Table 2-9).31'32 2-6). At preconvulsant local anesthetic blood levels, observed
Further increases in local anesthetic blood level result clinical signs and symptoms are produced because the local
in cessation of seizure activity as electroencephalographic anesthetic selectively depresses the action of inhibitory
(EEG) tracings become flattened, indicative of a generalized neurons (Fig. 2-7). Balance then is tipped slightly in favor of
CNS depression. Respiratory depression occurs at this time, excessive facilitatory (excitatory) input, leading to symptoms
eventually leading to respiratory arrest if anesthetic blood of tremor and slight agitation.
levels continue to rise. Respiratory effects are a result of the At higher (convulsive) blood levels, inhibitory neuron
depressant action of the local anesthetic drug on the CNS. function is completely depressed, allowing unopposed func­
Mechanism of Preconvulsant and Convulsant Actions. tion of facilitatory neurons (Fig. 2-8). Pure facilitatory input
It is known that local anesthetics exert a depressant action without inhibition produces the tonic-clonic activity
on excitable membranes, yet the primary clinical manifesta­ observed at these levels.
tion associated with high local anesthetic blood levels is Further increases in anesthetic blood level lead to depres­
related to varying degrees of stimulation. How can a drug sion of the facilitatory and inhibitory pathways, producing
that depresses the CNS be responsible for the production of generalized CNS depression (Fig. 2-9). The precise site of
varying degrees of stimulation, including tonic-clonic action of the local anesthetic within the CNS is not known
seizure activity? It is thought that local anesthetics produce but is thought to be at the inhibitory cortical synapses or
clinical signs and symptoms of CNS excitation (including directly on the inhibitory cortical neurons.

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CHAPTER2 Pharmacology of LocalAnesthetics 33

Figure 2-6. Balancebetween inhibitory and facilitatoryimpulses Figure 2-8. In the convulsivestageoflocal anesthetic action, the
in a normal cerebral cortex. inhibitory impulse is totally depressed,permitting unopposed facil­
itatory impulse activity.

~
I
x
I ''

Figure 2- 7. In the preconvulsivestage oflocal anesthetic action, Figure 2-9. In the final stage of local anesthetic action, both
the inhibitory impulse is more profoundly depressed than the inhibitory and facilitatory impulses are totally depressed,produc­
facilitatory impulse. ing generalizedcentral nervous system depression.

Analgesia. Localanestheticspossessa second action in rela­ despite documentation of both catastrophic events (mood
tion to the CNS.Administered intravenously,they increase elevation) and lack of effect (rejuvenation).
the pain reaction threshold and also produce a degree of Cocainehas long been used for its euphoria-inducing and
analgesia. fatigue-lesseningactions, dating back to the chewingof coca
In the 1940sand 1950s,procaine was administered intra­ leavesby Incas and other South American natives.38.39 Unfor­
venouslyfor the management of chronic pain and arthritis.37 tunately, as is well documented today, prolonged use of
The "procaine unit" was commonly used for this purpose; it cocaineleadsto habituation. William StewartHalsted (1852-
consisted of 4 mg/kg of body weight administered over 20 1922), the father of American surgery, cocaine researcher,
minutes. The technique was ineffective for acute pain. and the first person to administer a local anestheticby injec­
Becauseof the relativelynarrow safety margin between the tion, sufferedgreatlybecause of an addiction to cocaine." In
analgesicactions of procaine and the occurrence of signsand more recent times, the sudden, unexpected deaths of several
symptoms of overdose, this technique is no longer in use prominent professional athletes caused by cocaine and the
today. addiction of many others clearly demonstrate the dangers
involvedin the casual use of potent drugs.41•42
Mood Elevation. The use of local anesthetic drugs for More benign, but totally unsubstantiated, is the use
mood elevationand rejuvenation has persistedfor centuries, of procaine (Novocain) as a rejuvenating drug. Clinics

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34 PARTI The Drugs

vomiting, tremor, paresthesias,agranulocytosis,and pulmo­


TABLE 2-10 nary fibrosis.53·54Tocainideworsens symptoms of congestive
Intravenous Dose of Local Anesthetic Agents Required heart failure in about 5% of patients and may provoke
for Convulsive Activity (CD100}and Irreversible dysrhythmias (i.e.,is prodysrhythmic) in 1% to 8%.55
Cardiovascular Collapse (LD100}in Dogs Blood levels of lidocaine usually noted after intraoral
LD100/CD100 injection of one or two dental cartridges, 0.5 to 2 µg/mL,are
Agent CD1oo.mg/kg LD100.mg/kg Agent Ratio not associated with cardiodepressant activity. Increasing
Lidocaine 22 76 3.5 lidocaine blood levels slightlyis nontoxic and is associated
Etidocaine 8 40 5.0 with antidysrhythmic actions. Therapeutic blood levels of
Bupivacaine 4 20 5.0 lidocaine for antidysrhythmic activity range from 1.8 to
Tetracaine 5 27 5.4 6 µg/mL.48,56
Data from Llu P, et al: Acute cardiovascular toxicity of intravenous amide Lidocaineusuallyis administered intravenouslyin a bolus
local anesthetics in anesthetized ventilated dogs, Anesth Analg of 50 to 100 mg at a rate of 25 to 50 mg/min. This dose is
61:317-322, 1982. based on 1 to 1.5 mg/kg of body weight every 3 to 5 minutes
and is frequently followedby a continuous IV infusion of 1
to 4 mg/min. Signs and symptoms of local anesthetic over­
professingto "restore youthful vigor" claim that procaine is dose will be noted if the blood level rises beyond 6 µg/mL
a literal Fountain of Youth. These clinics operate primarily ofblood.56
in central Europe and Mexico,where procaine is used under Lidocaineis used clinicallyprimarily in the management
the proprietary name Gerovital.de Jong statesthat "whatever of PVCs and ventricular tachycardia. It also is used as a
the retarding effect on aging, it probably is relegated most (class-indeterminate) drug in advanced cardiovascular life
charitably to mood elevation.?" support and in management of cardiacarrest causedby ven­
tricular fibrillation.57
Cardiovascular System Direct cardiac actions of local anesthetics at blood levels
Local anesthetics have a direct action on the myocardium greater than the therapeutic (antidysrhythmic) levelinclude
and peripheral vasculature.In general,however,the cardio­ a decreasein myocardialcontractility and decreasedcardiac
vascular system appears to be more resistant than the CNS output, both of which lead to circulatory collapse (seeTable
to the effectsoflocal anesthetic drugs (Table 2-10).44 2-10).
Box 2-3 summarizes the CNS and cardiovascular effects
Direct Action on the Myocardium. Local anesthetics of increasinglocal anesthetic blood levels.
modify electrophysiologicevents in the myocardium in a
manner similar to their actions on peripheral nerves. As the Direct Action on the Peripheral Vasculature. Cocaine is
local anesthetic blood level increases, the rate of rise of the only local anesthetic drug that consistently produces
various phases of myocardial depolarization is reduced. No vasoconstriction at commonly employed dosages.4Ropiva­
significant change in resting membrane potential occurs, caine causes cutaneous vasoconstriction, whereas its conge­
and no significantprolongation of the phases of repolariza­ ner bupivacaine produces vasodilation.58All other local
tion is seen.45 anestheticsproduce a peripheral vasodilation through relax­
Local anesthetics produce a myocardial depression that ation of smooth muscle in the walls of blood vessels.This
is related to the local anesthetic blood level. Local anes­ leads to increased blood flow to and from the site of local
thetics decreasethe electricalexcitabilityof the myocardium, anesthetic deposition (see Table 2-1). Increased local blood
decrease the conduction rate, and decrease the force of flowincreasesthe rate of drug absorption, in turn leading to
contraction.46-48 decreased depth and duration of local anesthetic action,
Therapeutic advantage is taken of this depressant action increasedbleeding in the treatment area, and increasedlocal
in managing the hyperexcitablemyocardium, which mani­ anesthetic blood levels.
fests as various cardiac dysrhythmias.Although many local Table 2-11 provides examples of peak blood levels
anesthetics have demonstrated antidysrhythmic actions in achievedafter localanesthetic injection with and without the
animals, only procaine and lidocaine have gained signifi­ presence of a vasopressor.P'"
cant clinical reliability in humans. Lidocaine is the most The primary effectof local anesthetics on blood pressure
widely used and intensivelystudied local anesthetic in this is hypotension. Procaine produces hypotension more fre­
regard.9•29•49·50
Procainamideis the procaine moleculewith an quentlyand significantlythan doeslidocaine:50% of patients
amide linkage replacing the ester linkage.Becauseof this, it in one study receiving procaine became hypotensive, com­
is hydrolyzedmuch more slowlythan procaine.51Tocainide, pared with 6% of those receivinglidocaine.61This action is
a chemical analog of lidocaine, was introduced in 1984 as produced by direct depression of the myocardium and
an oral antidysrhythmic drug, because lidocaine is ineffec­ smooth muscle relaxation in the vessel walls by the local
tive after oral administration. 52Tocainide also is effective anesthetic.
in managing ventricular dysrhythmiasbut is associatedwith In summary,negativeeffectson the cardiovascularsystem
a 40% incidence of adverse effects, including nausea, are not noted until significantly elevated local anesthetic

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CHAPTER 2 Pharmacology of LocalAnesthetics 35

BOX 2-3 Minimal to Moderate Overdose Levels


Signs Symptoms (progressive with increasing blood levels}
Talkativeness Lightheadednessand dizziness
Apprehension Restlessness
Excitability Nervousness
Slurred speech Sensation of twitching before actual twitching is observed
Generalizedstutter, leading to muscular twitching and (see"Generalizedstutter" under "SIGNS")
tremor in the face and distal extremities Metallictaste
Euphoria Visual disturbances (inability to focus)
Dysarthria Auditory disturbances (tinnitus)
Nystagmus Drowsinessand disorientation
Sweating Loss of consciousness
Vomiting
Failureto follow commands or be reasoned with
Elevatedblood pressure
Elevatedheart rate
Elevatedrespiratory rate

Moderate to High Overdose Levels


Tonic-clonic seizure activity followedby
Generalizedcentral nervous system depression
Depressedblood pressure, heart rate, and respiratory rate
From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.

TABLE 2-11
Peak Plasma Levels Following Local Anesthetic Administration With and Without Vasopressor
Injection Site Anesthetic Dose, mg Epinephrine Dilution Peak Level, µg/mL
Infiltration Lidocaine 400 None 2.0
Infiltration Lidocaine 400 1:200,000 1.0
Intercostal Lidocaine 400 None 6.5
Intercostal Lidocaine 400 1:200,000 5.3
Intercostal Lidocaine 400 1:80,000 4.9
Infiltration Mepivacaine 5mg/kg None 1.2
Infiltration Mepivacaine 5mg/kg 1:200,000 0.7
Data from Kopacz DJ, Carpenter RL, Mackay DL: Effect of ropivacaine on cutaneous capillary flow in pigs, Anesthesiology 71:69, 1989; Scott DB, et al:
Factors affecting plasma levels of lignocaine and prilocaine, Br J Anaesth 44:1040-1049, 1972; Duhner KG, et al: Blood levels of mepivacaine after regional
anaesthesia, Br J Anaesth 37:746-752, 1965.

blood levels are reached. The usual sequence of local 4. At lethal levels,cardiovascularcollapseis noted. This is
anesthetic-induced actions on the cardiovascular system is caused by massiveperipheral vasodilation and decreased
as follows: myocardial contractility and heart rate (sinus
1. At nonoverdose levels,a slight increase or no change in bradycardia).
blood pressure occurs because of increased cardiac 5. Certain local anesthetics such as bupivacaine (and
output and heart rate as a result of enhanced to a lesser degree ropivacaineand etidocaine) may
sympathetic activity; direct vasoconstriction of certain precipitate potentially fatal ventricular fibrillation.62•63
peripheral vascular beds is also noted.
2. At levelsapproaching yet still below overdose,a mild Local Tissue Toxicity
degree of hypotension is noted; this is produced by a Skeletal muscle appears to be more sensitive than other
direct relaxant action on the vascular smooth muscle. tissues to the local irritant properties of local anesthetics.
3. At overdoselevels,profound hypotension is caused by Intramuscular and intraoral injection of articaine,lidocaine,
decreasedmyocardial contractility,cardiac output, and mepivacaine, prilocaine, bupivacaine, and etidocaine can
peripheral resistance. produce skeletal muscle alterations.v'"" It appears that

www.ShayanNemoodar.com
36 PARTI The Drugs

longer-acting local anesthetics cause more localized skeletal be absolutely contraindicated in MR-susceptible patients. 68
muscle damage than shorter-acting drugs. The changes that The Malignant Hyperthermia Association of the United
occur in skeletal muscle are reversible, with muscle regenera­ States (MHAUS), after evaluating recent clinical research,
tion being complete within 2 weeks after local anesthetic concluded that in fact no documented cases in the
administration. These muscle changes have not been associ­ medical or dental literature (over the past 30 years) support
ated with any overt clinical signs of local irritation. the concept of amide anesthetics triggering malignant
hyperthermia. 69-73
Respiratory System MHAUS maintains a Website with information for both
Local anesthetics exert a dual effect on respiration. At non­ health care providers and patients: www.mhaus.org.
overdose levels, they have a direct relaxant action on bron­
chial smooth muscle, whereas at overdose levels, they may References
produce respiratory arrest as a result of generalized CNS 1. Aps C, ReynoldsF: The effectof concentration in vasoactivity
depression. In general, respiratory function is unaffected by of bupivacaine and lignocaine, Br J Anaesth 48:1171-1174,
local anesthetics until near-overdose levels are achieved. 1976.
2. Covino BG: Pharmacology of local anaesthetic agents, Br J
Miscellaneous Actions Anaesth 58:701-716, 1986.
Neuromuscular Blockade. Many local anesthetics have 3. U.S.Food and Drug Administration: Center for Drug Evalua­
tion and Research:Approvalletter for phentolamine mesylate,
been demonstrated to block neuromuscular transmission in
1998.Availableat: www.fda.gov/cder/foi/anda/98/40235ap.pdf.
humans. This is a result of the inhibition of sodium diffusion
AccessedNovember 6, 2007.
through a blockade of sodium channels in the cell mem­ 4. BenowitzNL:Clinicalpharmacologyand toxicologyof cocaine,
brane. This action normally is slight and usually is clinically Pharmacol Toxicol72:1-12, 1993.
insignificant. On occasion, however, it can be additive to that 5. Arthur GR:Pharmacokineticsoflocal anesthetics.In Strichartz
produced by both depolarizing (e.g., succinylcholine) and GR,editor: Localanesthetics:handbook of experimentalphar­
nondepolarizing (e.g., atracurium, vecuronium) muscle macology,vol 81, Berlin, 1987,Springer-Verlag.
relaxants; this may lead to abnormally prolonged periods of 6. Hohnloser SH, Lange HW, Raeder E, et al: Short- and long­
muscle paralysis. Such actions are unlikely to occur in the term therapy with tocainide for malignant ventricular tachyar­
dental outpatient. rhythmias, Circulation 73:143-149, 1986.
7. Soliman IE, Broadman LM, Hannallah RS,McGillWA:Com­
parison of the analgesiceffectsof EMLA(eutectic mixture of
Drug Interactions. In general, CNS depressants (e.g.,
local anesthetics) to intradermal lidocaine infiltration prior to
opioids, antianxiety drugs, phenothiazines, barbiturates),
venous cannulation in unpremedicated children, Anesthesiol­
when administered in conjunction with local anesthetics, ogy 68:804--806,1988.
lead to potentiation of the CNS-depressant actions of the 8. American Heart Association:ACLSprovider manual, Dallas,
local anesthetic. The conjoint use of local anesthetics and Tex,2001,American Heart Association,pp 83-84.
drugs that share a common metabolic pathway can produce 9. Haugh KH:Antidysrhythmic agents at the turn of the twenty­
adverse reactions. Both ester local anesthetics and the depo­ first century: a current review,Crit Care Nursing Clin North
larizing muscle relaxant succinylcholine require plasma Am 14:13-69,2002.
pseudocholinesterase for hydrolysis. Prolonged apnea may 10. KalowW: Hydrolysisof local anestheticsby human serum cho­
result from concomitant use of these drugs. linesterase,J Pharmacol Exp Ther 104:122-134,1952.
Drugs that induce the production of hepatic microsomal 11. Watson CB: Respiratory complications associated with anes­
thesia, Anesth Clin North Am 20:375--399,2002.
enzymes (e.g., barbiturates) may alter the rate at which
12. Harris WH, Cole DW, Mital M, Laver MB: Methemoglobin
amide local anesthetics are metabolized. Increased hepatic
formation and oxygentransport followingintravenous regional
microsomal enzyme induction increases the rate of metabo­ anesthesia using prilocaine, Anesthesiology29:65, 1968.
lism of the local anesthetic. 13. Arthur GR: Distribution and elimination of local anesthetic
Specific drug-drug interactions related to the administra­ agents: the role of the lung, liver, and kidneys, PhD thesis,
tion oflocal anesthetics are reviewed in Chapter 10. Edinburgh, 1981,Universityof Edinburgh.
14. Oertel R, Berndt A. Kirch W: Saturable in vitro metabolism
Malignant Hyperthermia. Malignant hyperthermia (MH; of articaine by serum esterases:does it contribute to the resis­
hyperpyrexia) is a pharmacogenic disorder in which a genetic tance of the local anesthetic effect? Reg Anesth 21:576-581,
variant in an individual alters that person's response to 1996.
certain drugs. Acute clinical manifestations of MH include 15. Nation RL,TriggsEJ:Lidocainekineticsin cardiacpatients and
aged subjects,Br J Clin Pharmacol 4:439--448,1977.
tachycardia, tachypnea, unstable blood pressure, cyanosis,
16. Thomson PD, Melmon KL, Richardson JA. et al: Lidocaine
respiratory and metabolic acidosis, fever (as high as 42° C
pharmacokinetics in advanced heart failure, liver disease,and
[108° F] or more), muscle rigidity, and death. Mortality renal failure in humans, Ann Intern Med 78:499-508, 1973.
ranges from 63% to 73%. Many commonly used anesthetic 17. Oertel R, Rahn R, KirchW: Clinicalpharmacokinetics of artic­
drugs can trigger MH in certain individuals. aine, Clin Pharmacokinet 33:617--625,1997.
Until recently, the amide local anesthetics were thought 18. Prilocaine-induced methemoglobinemia-Wisconsin, 1993,
to be capable of provoking MH and were considered to MMWR Morb Mortal Wkly Rep 43:3555-3557,1994.

www.ShayanNemoodar.com
CHAPTER 2 Pharmacologyof LocalAnesthetics 37

19. Wilburn-Goo D, Lloyd LM: When patients become cyanotic: 42. Harriston K, Jenkins S: Maryland basketball star Len Bias is
acquired methemoglobinemia, J Am Dent Assoc 130:626--631, dead at 22. Washington Post, 20 June 1986.
1999. 43. de Jong RH: Local anesthetics, ed 2, Springfield, Ill, 1977,
20. Strong JM, Parker M, Atkinson AJ Jr: Identification of glycinex­ Charles C Thomas, p 89.
ylidide in patients treated with intravenous lidocaine, Clin 44. Scott DB: Toxicity caused by local anaesthetic drugs, Br J
Pharmacol Ther 14:67-72, 1973. Anaesth 53:553-554, 1981.
21. Gupta PP, Tangri AN, Saxena RC, Dhawan BN: Clinical phar­ 45. Pinter A, Dorian P: Intravenous anti.arrhythmic agents, Curr
macology studies on 4-N-butylamino-1,2,3,4,-tetrahydroacri­ Opin Cardiol 16:17-22, 2001.
dine hydrochloride (Centbucridine), a new local anaesthetic 46. Sugi K: Pharmacological restoration and maintenance of sinus
agent, Indian J Exp Biol 20:344-346, 1982. rhythm by antiarrhythmic agents, J Cardiol 33(Suppl 1):59--64,
22. Vacharajani GN, Parikh N, Paul T, Satoskar RS: A comparative 1999.
study of Centbucridine and lidocaine in dental extraction, Int 47. Alexander JH, Granger CB, Sadowski Z, et al: Prophylactic
J Clin Pharmacol Res 3:251-255, 1983. lidocaine use in acute myocardial infarction: incidence and
23. Bernhard CG, Bohm E: Local anaesthetics as anticonvulsants: outcomes from two international trials. The GUSTO-I and
a study on experimental and clinical epilepsy, Stockholm, 1965, GUSTO-lib Investigators, Am Heart J 137:599-805, 1999.
Almqvist & Wiksell. 48. Cannom DS, Prystowsky EN: Management of ventricular
24. Bernhard CG, Bohm E, Wiesel T: On the evaluation of the arrhythmias: detection, drugs, and devices, JAMA 281:272-
anti.convulsive effect of different local anesthetics, Arch Int 279, 1999.
Pharmacodyn Ther 108:392-407, 1956. 49. Tan HL, Lie KI: Prophylactic lidocaine use in acute myocardial
25. Julien RM: Lldocaine in experimental epilepsy: correlation of infarction revisited in the thrombolytic era, Am Heart J
anticonvulsant effect with blood concentrations, Electroen­ 137:570-573, 1999.
cephalogr Clin Neurophysiol 34:639--645, 1973. 50. Kowey PR: An overview of antiarrhythmic drug management
26. Berry CA, Sanner JH, Keasling HH: A comparison of the anti­ of electrical storm, Can J Cardiol 12(Suppl B):3B-8B; discus­
convulsant activity of mepivacaine and lidocaine, J Pharmacol sion 27B-28B, 1996.
Exp Ther 133:357-363, 1961. 51. Slavik RS, Tisdale JE, Borzak S: Pharmacologic conversion of
27. Walker IA, Slovis CM: Lidocaine in the treatment of status atrial fibrillation: a systematic review of available evidence,
epilepticus, Acad Emerg Med 4:918--922, 1997. Prog Cardiovasc Dis 44:221-252, 2001.
28. Chen AH: Toxicity and allergy to local anesthesia, J Calif Dent 52. Lalka D, Meyer MB, Duce BR, Elvin AT: Kinetics of the oral
Assoc 26:983--992, 1998. antiarrhythmic lidocaine congener, tocainide, Clin Pharmacol
29. Katz J, Feldman MA, Bass EB, et al: Injectable versus topical Ther 19:757-766, 1976.
anesthesia for cataract surgery: patient perceptions of pain and 53. Perlow GM, Jain BP, Pauker SC, et al: Tocainide-associated
side effects: the Study of Medical Testing for Cataract Surgery interstitial pneumonitis, Ann Intern Med 94(4 Pt 1):489-490,
Study Team, Ophthalmology 107:2054-2060, 2000. 1981.
30. Bureau of Medicine and Surgery. Available at: http:// 54. Volosin K, Greenberg RM, Greenspon AJ: Tocainide associated
navymedicine.med.navy.mil/. Accessed October 28, 2011. agranulocytosis, Am Heart J 109:1392, 1985.
31. Englesson S: The influence of acid-base changes on central 55. Bronheim D, Thys DM: Cardiovascular drugs. In Longnecker
nervous system toxicity of local anesthetic agents. I. An experi­ DE, Tinker JH, Morgan GE Jr, editors: Principles and practice
mental study in cats, Acta Anaesthesiol Scand 18:79, 1974. of anesthesiology, ed 2, St Louis, 1998, Mosby.
32. Englesson S, Grevsten S, Olin A; Some numerical methods of 56. Kudenchuk PJ: Advanced cardiac life support antiarrhythmic
estimating acid-base variables in normal human blood with a drugs, Cardiol Clin 20:19-87, 2002.
haemoglobin concentration of 5 g-100 cm3, Scand J Lab Clin 57. American Heart Association: Guidelines 2000 for cardiopul­
Invest 32:289-295, 1973. monary resuscitation and emergency cardiovascular care,
33. de Jong RH, Robles R, Corbin RW: Central actions oflidocaine­ Circulation 102:8--149, 2000.
synaptic transmission, Anesthesiology 30:19, 1969. 58. Kopacz DJ, Carpenter RL, MacKay DL: Effect of ropivacaine
34. Huffman RD, Yun GKW: Effects of diphenylaminoethanol and on cutaneous capillary flow in pigs, Anesthesiology 71:69,
lidocaine on central inhibition, Int J Neuropharmacol 8:217, 1989.
1969. 59. Scott DB, Jebson PJR, Braid DP, et al: Factors affecting plasma
35. Tanaka K, Yamasaki M: Blocking of cortical inhibitory synapses levels oflignocaine and prilocaine, Br J Anaesth 44:1040-1049,
by intravenous lidocaine, Nature 209:207, 1966. 1972.
36. de Jong RH: Local anesthetics, St Louis, 1994, Mosby. 60. Duhner KG, Harthon JGL, Hebring BG, Lie T: Blood levels of
37. Graubard DJ, Peterson MC: Clinical uses of intravenous pro­ mepivacaine after regional anaesthesia, Br J Anaesth 37:746-
caine, Springfield, Ill, 1950, Charles C Thomas. 752, 1965.
38. Garcilasso de la Vega: Commentarios reales de los Incas (1609- 61. Kimmey JR, Steinhaus JE: Cardiovascular effects of procaine
1617). In Freud S, editor: Uber coca, Wien, 1884, Verlag von and lidocaine (Xylocaine) during general anesthesia, Acta
Moritz Perles. Anaesthesiol Scand 3:9-15, 1959.
39. Disertacion sobre el aspecto, cultivo, comercio y virtudes de la 62. de Jong RH, Ronfeld R, DeRosa R: Cardiovascular effects of
famosa planta del Peru nombrado coca: Lima, 1794. In Freud convulsant and supraconvulsant doses of amide local anesthet­
S, editor: Uber coca, Wien, 1884, Verlag von Moritz Perles. ics, Anesth Analg 61:3, 1982.
40. Olch PD, William S: Halsted and local anesthesia: contribu­ 63. Feldman HS, Arthur GR, Covino BG: Comparative systemic
tions and complications, Anesthesiology 42:479-486, 1975. toxicity of convulsant and supraconvulsant doses of intrave­
41. Preboth M: Cocaine abuse among athletes, Am Fam Physician nous ropivacaine, bupivacaine and lidocaine in the conscious
62:1850-2000, 1915. dog, Anesth Analg 69:794, 1989.

www.ShayanNemoodar.com
38 PARTI The Drugs

64. Zink W, Graf BM, Sinner B, et al: Differential effects of 69. Gielen M, Viering W: 3-in-1 lumbar plexus block for muscle
bupivacaine on intracellular ea2+ regulation: potential mecha­ biopsy in malignant hyperthermia patients: amide local anaes­
nisms of its myotoxicity,Anesthesiology97:710-716,2002. thetics maybe used safely,ActaAnaesthesiolScand30:581-583,
65. Irwin W,Fontaine E,AgnolucciL,et al: Bupivacainemyotoxic­ 1986.
ity ismediated by mitochondria, J BiolChem 277:12221-12227, 70. Ording H: Incidence of malignant hyperthermia in Denmark,
2002. Anesth Analg 64:700-704, 1985.
66. Benoit PW, YagielaJA, Fort NF: Pharmacologic correlation 71. Paasuke PT, Brownell AKW: Amine local anaesthetics and
between local anesthetic-induced myotoxicity and distur­ malignant hyperthermia (editorial),Can AnaesthSocJ 33:126-
bances of intracellularcalciumdistribution, ToxicolAppl Phar­ 129, 1986.
macol 52:187-198, 1980. 72. JastakJT,YagielaJA,Donaldson D: Localanesthesia of the oral
67. Hinton RJ, Dechow PC, Carlson DS: Recoveryof jaw muscle cavity,Philadelphia, 1995,WB Saunders,pp 141-142.
function following injection of a myotoxic agent (lidocaine­ 73. Malignant Hyperthermia Association of the United States.
epinephrine), Oral Surg Oral Med Oral Pathol 59:247-251, Availableat: www.mhaus.org.AccessedOctober 28, 2011.
1986.
68. Denborough MA, Forster JF, Lovell RR, et al: Anaesthetic
deaths in a family,Br J Anaesth 34:395-396, 1962.

www.ShayanNemoodar.com
T

Pharmacology
of Vasoconstrictors

All clinicallyeffectiveinjectablelocal anesthetics are vasodi­ bleeding is anticipated (e.g.,during a surgical


lators, the degree of vasodilation varying from significant procedure).5'6
{procaine) to minimal {prilocaine, mepivacaine) and also The vasoconstrictors commonly used in conjunction
possiblywith both the injection site and individual patient with injected local anesthetics are chemically identical or
response.After local anesthetic injection into tissues,blood similar to the sympathetic nervous system mediators epi­
vessels(arteriolesand capillariesprimarily) in the area dilate, nephrine and norepinephrine. The actions of the vasocon­
resulting in increased perfusion at the site, leading to the strictors so resemble the response of adrenergic nerves to
followingreactions: stimulation that they are classifiedas sympathomimetic, or
1. An increased rate of absorption of the local anesthetic adrenergic, drugs. These drugs have many clinical actions
into the cardiovascularsystem,which in turn removes it besides vasoconstriction.
from the injection site (redistribution) Sympathomimeticdrugs also may be classifiedaccording
2. Higher plasma levelsof the local anesthetic, with an to their chemical structure and mode of action.
attendant increase in the risk of local anesthetic toxicity
(overdose)
3. Decreasein both the depth and duration of anesthesia
CHEMICAL STRUCTURE
because the local anesthetic diffusesawayfrom the Classificationof sympathomimetic drugs by chemicalstruc­
injection site more rapidly ture is related to the presence or absence of a catechol
4. Increased bleeding at the site of treatment as a result of nucleus. Catechol is orthodihydroxybenzene.Sympathomi­
increased perfusion metic drugs that have hydroxyl (OH) substitutions in the
Vasoconstrictors are drugs that constrict blood vessels third and fourth positions of the aromatic ring are termed
and thereby control tissue perfusion. They are added to local catechols.
anesthetic solutions to oppose the inherent vasodilatory
actions of the local anesthetics.Vasoconstrictorsare impor­
tant additions to a local anesthetic solution for the following
reasons:
1. By constricting blood vessels,vasoconstrictors decrease
HO -9-
HO
CH-CH-NH
I
OH
I
G)
I
@
blood flow {perfusion)to the site of drug
administration.
2. Absorption of the local anesthetic into the
<D ®
cardiovascularsystem is slowed,resulting in lower
Epinephrine H CH3
anesthetic blood levels.P Table3-1 illustrates levelsof
local anesthetic in the blood with and without a Levonordefrin CH3 H
vasoconstrictor.1 Norepinephrine H H
3. Localanesthetic blood levelsare lowered,thereby
decreasingthe risk of local anesthetic toxicity.
4. More local anesthetic enters into the nerve, where it If they also contain an amine group (NH2) attached to
remains for longer periods, thereby increasing (in some the aliphatic side chain, they are then called catecholamines.
cases significantly,3in others minimally4) the duration Epinephrine, norepinephrine, and dopamine are the natu­
of action of most local anesthetics. rally occurring catecholamines of the sympathetic nervous
5. Vasoconstrictorsdecreasebleeding at the site of system. Isoproterenol and levonordefrin are synthetic
administration; therefore they are useful when increased catecholamines.
39

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40 PARTI The Drugs

TABLE 3-1 BOX 3-1 Categories of Sympathomimetic Amines


Effects of Vasoconstrictor (Epinephrine 1 : 200,000) on
Mixed­
Peak Local Anesthetic Levels in Blood
Direct-Acting Indirect-Acting Acting
PEAK LEVEL. µg/ml Epinephrine Tyramine Metaraminol
Local Dose, Without With Norepinephrine Amphetamine Ephedrine
Anesthetic mg Vasoconstrictor Vasoconstrictor Levonordefrin Methamphetamine
Mepivacaine 500 4.7 3 Isoproterenol Hydroxyamphetamine
Lidocaine 400 4.3 3 Dopamine
Prilocaine 400 2.8 2.6 Methoxamine
Etidocaine 300 1.4 1.3 Phenylephrine
Data from Cannall H, Walters H, Beckett AH, Saunders A:. Circulating
blood levels of lignocaine after peri-oral injections, Br Dent J 138:87-93,
1975.

TABLE 3-2
Adrenergic Receptor Activity of Vasoconstrictors
Vasoconstrictorsthat do not possess OH groups in the Drug a, ai p,
third and fourth positions of the aromatic molecule are not
Epinephrine +++ +++ +++ +++
catechols but are amines because they have an NH2 group
Norepinephrine ++ ++ ++ +
attached to the aliphatic side chain.
Levonordefrin + ++ ++ +
Catecholamines Noncatecholamines Relative potency of drugs is indicated as follows: +++, high, ++,
Epinephrine Amphetamine intermediate, and +, low.
From Jastak JT,Yagiela JA, Donaldson D: Local anesthesia of the oral
Norepinephrine Methamphetamine cavity, Philadelphia, 1995, WB Saunders.
Levonordefrin Ephedrine
Isoproterenol Mephentermine
Dopamine Hydroxyamphetamine
Metaraminol have since been subcategorized. Whereas a.1 receptors
Methoxamine are excitatory-postsynaptic, a.i receptors are inhibitory­
Phenylephrine postsynaptic.8
Activation of P receptors produces smooth muscle relax­
Felypressin,a synthetic analog of the polypeptide vaso­ ation (vasodilationand bronchodilation) and cardiac stimu­
pressin (antidiuretic hormone), is availablein many coun­ lation (increased heart rate and strength of contraction).
tries as a vasoconstrictor. As of the time of this writing Beta receptors are further divided into Pt> and P2:P1
(November 2011), felypressinis not availablein the United are found in the heart and small intestines and are respon­
States. sible for cardiac stimulation and lipolysis; p2, found in the
bronchi, vascularbeds, and uterus, produce bronchodilation
and vasodilation.9
MODES OF ACTION Table 3-2 illustrates the differences in varying degrees
Three categories of sympathomimetic amines are known: of a. and p receptor activity of three commonly used
direct-acting drugs, which exert their action directly on vasoconstrictors.
adrenergic receptors; indirect-acting drugs, which act by Table 3-3 lists the systemic effects, based on a. and P
releasing norepinephrine from adrenergic nerve terminals; receptor activity,of epinephrine and norepinephrine.
and mixed-acting drugs, with both direct and indirect
actions (Box3-1).1-3 Release of Catecholamines
Other sympathomimetic drugs, such as tyramine and
Adrenergic Receptors amphetamine, act indirectly by causing the release of the
Adrenergic receptors are found in most tissues of the body. catecholamine norepinephrine from storage sites in adren­
The concept of adrenergic receptors was proposed by ergic nerve terminals. In addition, these drugs may exert
Ahlquist in 1948and is well acceptedtoday.7 Ahlquist recog­ direct action on a. and P receptors.
nized two types of adrenergicreceptor,termed alpha (a.) and The clinical actions of this group of drugs therefore are
beta (p), based on inhibitory or excitatory actions of cate­ quite similar to the actions of norepinephrine. Successively
cholamines on smooth muscle. repeated doses of these drugs will prove to be less effective
Activation of a. receptors by a sympathomimetic drug than those given previouslybecause of depletion of norepi­
usually produces a response that includes contraction of nephrine from storage sites. This phenomenon is termed
smooth muscle in blood vessels (vasoconstriction). Based tachyphylaxis and is not seen with drugs that act directly on
on differences in their function and location, a. receptors adrenergic receptors.

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CHAPTER 3 Pharmacology of Vasoconstrictors 41

interpretations should enable the reader to convert these


DILUTIONS OF VASOCONSTRICTORS
terms readily:
The dilution of vasoconstrictors is commonly referred to as • A concentration of 1: 1000means that 1 g (1000 mg) of
a ratio (e.g., 1to1000[written1:1000]). Becausemaximum solute (drug) is contained in 1000mL of solution.
doses of vasoconstrictors are presented in milligrams, or • Therefore, a 1: 1000dilution contains 1000mg in
more commonly today as micrograms (µg), the following 1000mL or 1.0mg/mL of solution (1000 µg/mL).
Vasoconstrictors,as used in dental local anesthetic solu­
TABLE 3-3 tions, are much less concentrated than the 1: 1000dilution
Systemic Effects of Sympathomimetic Amines described in the preceding paragraph. To produce these
more dilute, clinicallysafer,yet effectiveconcentrations, the
Effector Organ
1: 1000 dilution must be diluted further. This process is
or Function Epinephrine Norepinephrine
described here:
Cardiovascular System • To produce a 1: 10,000concentration, 1 mL of a 1: 1000
Heart rate + solution is added to 9 mL of solvent (e.g., sterile water);
Strokevolume ++ ++ therefore 1: 10,000= 0.1 mg/mL (100 µg/mL).
Cardiac output +++ 0,-
• To produce a 1: 100,000concentration, 1 mL of a
Arrhythmias ++++ ++++
1: 10,000concentration is added to 9 mL of solvent;
Coronary blood flow ++ ++
Blood Pressure therefore 1: 100,000= 0.01 mg/mL (IO µg/mL).
Systolicarterial +++ +++ The milligram per milliliter and µg per milliliter values
Mean arterial + ++ of the various vasoconstrictor dilutions used in medicine
Diastolic arterial +,0,- ++ and dentistry are shown in Table3-4.
Peripheral Circulation The genesisof vasoconstrictor dilutions in local anesthet­
Total peripheral resistance ++ icsbegan with the discoveryof adrenalin in 1897by Abel.In
Cerebral blood flow + 0,- 1903,Braun suggestedusing adrenalin as a chemicaltourni­
Cutaneous blood flow - quet to prolong the duration of local anesthetics." Braun
Splanchnicblood flow +++ o,+ recommended the use of a 1: 10,000dilution of epinephrine,
Respiratory System ranging to as dilute as 1: 100,000,with cocaine in nasal
Bronchodilation +++ 0 surgery (a highlyvascular area). It appears at present that an
Genitourinary System epinephrine concentration of 1:200,000 provides compa­
Renalblood flow
rable results,with fewersystemicside effects.The 1:200,000
Skeletal Muscle
Muscleblood flow
dilution, which contains 5 µg/mL (or 0.005 mg/mL), has
+++ 0,-
Metabolic Effects become widely used in both medicine and dentistry and is
Oxygenconsumption ++ o,+ currently found in articaine, prilocaine, lidocaine (though
Blood glucose +++ 0,+ not in North America), etidocaine, and bupivacaine. In
Blood lactic acid +++ O,+ several European and Asian countries, lidocaine with epi­
nephrine concentrations of 1:300,000 and 1:400,000 is
Data from Goldenberg M, Aranow H Jr, Smith AA, Faber M:
Pheochromocytoma and essential hypertensive vascular disease, Arch availablein dental cartridges.
Intern Med 86:823-836, 1950. Although it is the most used vasoconstrictorin localanes­
+, Increase; -, decrease; 0, no effect. thetics in both medicine and dentistry,epinephrine is not an

TABLE 3-4
Concentrations of Clinically Used Vasoconstrictors
Concentration Milligrams per Micrograms per µg per Cartridge
(Dilution) Milliliter (mg/ml) Milliliter (µ.g/mL) (1.8 ml) Therapeutic Use
1:1000 1.0 1000 Epinephrine-Emergency medicine
(IM/SC anaphylaxis)
1:2500 0.4 400 Phenylephrine
1:10,000 0.1 100 Epinephrine-Emergency medicine
(IV/ET cardiac arrest)
1:20,000 0.05 50 90 Levonordefrin-Local anesthetic
1:30,000 0.033 33.3 73 (2.2-mL cartridge) Norepinephrine-Local anesthetic
1:50,000 0.02 20 36 Epinephrine-Local anesthetic
1:80,000 0.0125 12.5 27.5 (2.2-mL cartridge) Epinephrine-Local anesthetic
(United Kingdom)
1:100,000 O.ol 10 18 Epinephrine-Local anesthetic
1:200,000 0.005 5 9 Epinephrine-Local anesthetic
1:400,000 0.0025 2.5 4.5 Epinephrine-Local anesthetic

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42 PARTI The Drugs

ideal drug. The benefits to be gained from adding epineph­ phenylephrine 1:20,000 (lidocaineblood level= 2.4 µg/mL)
rine (or any vasoconstrictor, for that matter) to a local than with epinephrine 1:200,000 (1.4 µg/mL).23 The cardio­
anesthetic solution must be weighed against any risks that vascular effects of levonordefrin most closely resemble
might be present. Epinephrine is absorbed from the site those of norepinephrine.24 Felypressin was shown to be
of injection, just as is the local anesthetic. Measurable epi­ about as effective as epinephrine in reducing cutaneous
nephrine blood levelsare obtained, and these influence the blood flow.5
heart and blood vessels.Resting plasma epinephrine levels Epinephrine remains the most effective and the most
(39 pg/mL) are doubled after administration of one car­ used vasoconstrictor in medicine and dentistry.
tridge of lidocaine with 1: 100,000 epinephrine." Elevation
of epinephrine plasma levelsis linearly dose dependent and
persists from severalminutes to a half-hour.12 Contrary to a
PHARMACOLOGY OF SPECIFIC AGENTS
previously held position that intraoral administration of The pharmacologic properties of the sympathomimetic
usual volumes of epinephrine produced no cardiovascular amines commonlyused asvasoconstrictorsin local anesthet­
response, and that patients were more at risk from ics are reviewed.Epinephrine is the most useful and repre­
endogenously released epinephrine than they were from sents the best example of a drug mimicking the activity of
exogenouslyadministered epinephrine,13'14 recent evidence sympathetic discharge. Its clinical actions are reviewed in
demonstrates that epinephrine plasma levels equivalent to depth. The actions of other drugs are compared with those
those achievedduring moderate to heavyexercisemay occur of epinephrine.
after intraoral lnjection.":" These are associatedwith mod­
erate increasesin cardiac output and stroke volume (seethe
following section). Blood pressure and heart rate, however, Epinephrine
are minimally affectedat these dosages.17 Proprietary Name. Adrenalin.
In patients with preexisting cardiovascular or thyroid
disease, the side effects of absorbed epinephrine must be Chemical Structure. Epinephrine as the acid salt is highly
weighed against those of elevated local anesthetic blood soluble in water. Slightlyacid solutions are relativelystable
levels.It is currently thought that the cardiovasculareffects if they are protected from air. Deterioration (through oxida­
of conventional epinephrine doses are of little practical tion) is hastened by heat and the presence of heavy metal
concern, evenin patients with heart disease.12 However,even ions. Sodium bisulfite is commonly added to epinephrine
followingusual precautions (e.g.,aspiration, slowinjection), solutions to delaythis deterioration. The shelf life of a local
sufficientepinephrine can be absorbed to cause sympatho­ anesthetic cartridge containing a vasoconstrictor is some­
mimetic reactions such as apprehension, tachycardia,sweat­ what shorter (18 months) than that of a cartridge containing
ing, and pounding in the chest (palpitation)-the so-called no vasoconstrictor (36 months).
epinephrine reaction.18
Intravascular administration of vasoconstrictors and

NC
OHH
their administration to sensitive individuals (hyperre­ I I /H
sponders), or the occurrence of unanticipated drug-drug -C-N
interactions, can howeverproduce significantclinicalmani­ H ~ ~ ~Ha
festations. Intravenous administration of 0.015 mg of epi­ OH
nephrine with lidocaine results in an increase in the heart
rate ranging from 25 to 70 beats per minute, with elevations
in systolic blood from 20 to 70 mm Hg.12•19.2° Occasional Source. Epinephrine is available as a synthetic and is also
rhythm disturbances may be observed, and premature ven­ obtained from the adrenal medulla of animals (epinephrine
tricular contractions (PVCs)are most often noted. constitutes approximately 80% of adrenal medullary secre­
Other vasoconstrictors used in medicine and dentistry tions). It exists in both levorotatory and dextrorotatory
include norepinephrine, phenylephrine, levonordefrin, and forms; the levorotatory form is approximately 15 times as
felypressin.Norepinephrine, lacking significant p2 actions, potent as the dextrorotatory form.
produces intense peripheral vasoconstriction with possible
dramatic elevation of blood pressure, and is associatedwith Mode of Action. Epinephrine acts directly on both ex-and
a side effect ratio nine times higher than that of epineph­ P-adrenergic receptors; P effectspredominate.
rine." Although it is currently availablein some countries in
local anesthetic solutions, the use of norepinephrine as a Systemic Actions
vasopressor in dentistry is diminishing and cannot be rec­ Myocardium. Epinephrine stimulates p1 receptors of the
ommended. The use of a mixture of epinephrine and nor­ myocardium. There is a positiveinotropic (forceof contrac­
epinephrine is to be absolutely avoided.22 Phenylephrine, a tion) and a positivechronotropic (rate of contraction) effect.
pure cx-adrenergicagonist, theoretically possesses advan­ Both cardiac output and heart rate are increased.
tages over other vasoconstrictors.However,in clinicaltrials, Pacemaker Cells. Epinephrine stimulates p1 receptors
peak blood levels of lidocaine were actually higher with and increases the irritability of pacemaker cells,leading to

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CHAPTER3 Pharmacology of Vasoconstrictors 43

an increased incidence of dysrhythmias. Ventricular tachy­ Respiratory System. Epinephrine is a potent dilator (p2
cardia (VT) and premature ventricular contractions (PVCs) effect)of bronchiole smooth muscle.It is an important drug
are common. for management of more refractory episodes of broncho­
Coronary Arteries. Epinephrine produces dilation of spasm (e.g., status asthmaticus).
the coronary arteries, increasingcoronary artery blood flow. Central Nervous System. In usual therapeutic dosages,
Blood Pressure. Systolic blood pressure is increased. epinephrine is not a potent central nervous system (CNS)
Diastolicpressure is decreasedwhen small doses are admin­ stimulant. Its CNS-stimulating actions become prominent
istered because of the greater sensitivity to epinephrine when an excessivedose is administered.
of p2 receptors compared with a. receptors in vessels Metabolism. Epinephrine increases oxygen consump­
supplyingthe skeletalmuscles.Diastolicpressure is increased tion in all tissues. Through p action, it stimulates glycoge­
with larger epinephrine doses because of constriction of nolysis in the liver and skeletal muscle, elevating blood
blood vessels supplying the skeletal muscles caused by a. sugar levelsat plasma epinephrine concentrations of 150to
receptor stimulation. 200 pg/mL.25 The equivalent of four dental local anesthetic
Cardiovascular Dynamics. The overall action of epi­ cartridges of 1: 100,000epinephrine must be administered
nephrine on the heart and cardiovascular system is direct to elicit this response.27
stimulation: Termination of Action and Elimination. The action of
• Increased systolicand diastolicpressures epinephrine is terminated primarily by its reuptake by
• Increased cardiac output adrenergic nerves. Epinephrine that escapes reuptake is
• Increased stroke volume rapidly inactivated in the blood by the enzymes catechol-
• Increased heart rate 0-methyltransferase (COMT) and monoamine oxidase
• Increased strength of contraction (MAO),both of which are present in the liver.28 Only small
• Increased myocardial oxygenconsumption amounts {approximately 1%) of epinephrine are excreted
These actions lead to an overall decrease in cardiac unchanged in the urine.
efficiency. Side Effects and Overdose. The clinical manifestations
The cardiovascularresponses of increased systolicblood of epinephrine overdose relate to CNS stimulation and
pressure and increasedheart rate developwith the adminis­ include increasing fear and anxiety, tension, restlessness,
tration of one to two dental cartridges of a 1: 100,000epi­ throbbing headache, tremor, weakness, dizziness, pallor,
nephrine dilution.25 Administration of four cartridges of respiratory difficulty,and palpitation.
1: 100,000epinephrine will bring about a slight decrease in With increasing levels of epinephrine in the blood,
diastolicblood pressure. cardiac dysrhythmias (especiallyventricular) become more
Vasculature. The primary action of epinephrine is on common; ventricular fibrillation is a rare but possible con­
smaller arterioles and precapillary sphincters. Blood vessels sequence.Dramatic increasesin both systolic{>300mm Hg)
supplying the skin, mucous membranes, and kidneys pri­ and diastolic (>200 mm Hg) pressures may be noted and
marily contain a. receptors. Epinephrine produces constric­ have led to cerebral hemorrhage.29 Anginal episodes may be
tion in these vessels.Vesselssupplying the skeletal muscles precipitated in patients with coronary artery insufficiency.
contain both a. and p2 receptors, with p2 predominating. Becauseof the rapid inactivation of epinephrine, the stimu­
Smalldoses of epinephrine produce dilation of these vessels latory phase of the overdose (toxic) reaction usuallyis brief.
as a result of p2 actions. p2 receptors are more sensitive to Vasoconstrictor overdose is discussed in greater depth in
epinephrine than are a. receptors. Larger doses produce Chapter 18.
vasoconstriction because a. receptors are stimulated.
Hemostasis. Clinically, epinephrine is used frequently
as a vasoconstrictor for hemostasis during surgical proce­ Clinical Applications
dures. Injection of epinephrine directly into surgical sites • Management of acute allergicreactions
rapidly produces high tissue concentrations, predominant • Management of refractory bronchospasm (status
a. receptor stimulation, and hemostasis. As epinephrine asthmaticus)
tissue levelsdecreaseover time, its primary action on blood • Management of cardiac arrest
vesselsreverts to vasodilation because p2 actions predomi­ • As a vasoconstrictor,for hemostasis
nate; therefore it is common for some bleeding to be • As a vasoconstrictor in local anesthetics,to decrease
noted at about 6 hours after a surgical procedure. In a absorption into the cardiovascularsystem
clinicaltrial involvingextraction of third molars, postsurgi­ • As a vasoconstrictor in local anesthetics,to increase
calbleeding occurred in 13of16 patients receivingepineph­ depth of anesthesia
rine with their local anesthetic for hemostasis,whereas 0 of • As a vasoconstrictor in local anesthetics,to increase
16 patients receivinglocal anesthetic without vasoconstric­ duration of anesthesia
tor (mepivacaineplain) had bleeding 6 hours post surgery.26 • To produce mydriasis
Additional findings of increased postsurgical pain and Availability in Dentistry. Epinephrine is the most potent
delayed wound healing were noted in the epinephrine­ and widely used vasoconstrictor in dentistry. It is available
receivinggroup.26 in the followingdilutions and drugs:

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44 PART I The Drugs

Epinephrine Dilution Local Anesthetic (generic) York Heart Association recommended that maximal epi­
nephrine doses be limited to 0.2 mg per appointment.33In
1:50,000 Lldocaine
the followingyears,the American Heart Associationrecom­
1:80,000 Lldocaine (lignocaine)
(United Kingdom)
mended the restriction of epinephrine in local anesthetics
1:100,000 Articaine when administered to patients with ischemicheart disease.34
Lidocaine More recently, the Agency for Healthcare Research and
1:200,000 Articaine Quality (AHRQ) reviewed the published literature on the
Bupivacaine subject of the effectsof epinephrine in dental patients with
Etidocainet high blood pressure.35The report reviewed six studies that
Lidocaine evaluated the effects of dental treatment (extraction of
Mepivacaine* teeth) in hypertensive patients when they received local
Prilocaine anesthetics with and without epinephrine. Results suggest
1:300,000 Lldocaine* that hypertensivesubjects undergoing an extraction experi­
1:400,000 Articaine*
ence small increases in systolic blood pressure and heart
*Not availablein the United States (August2011). rate associatedwith the use of a local anesthetic containing
tNo longer marketed in the United State (2002). epinephrine. These increases associated with the use of
epinephrine occur in addition to increases in systolic and
diastolic blood pressures and heart rate associated with
Maximum Doses. The least concentrated solution that undergoing the procedure without epinephrine that are
produces effectivepain control should be used. Lidocaineis larger for hypertensive than for normotensive patients. No
availablewith two dilutions of epinephrine-I :50,000 and adverse outcomes were reported among any of the subjects
I : 100,000---in the United States and Canada, and with in the studies included in the review,and only one report of
I :80,000,I :200,000,and I :300,000dilutions in other coun­ an adverse event associated with the use of epinephrine in
tries. The duration of effectivepulpal and soft tissue anes­ local anesthetic in a hypertensive patient was identified in
thesia is equivalent with all forms. Therefore it is the literature (Table3-6).35
recommended (in North America) that the I : 100,000epi­ In cardiovascularly compromised patients, it seems
nephrine concentration be used with lidocaine when prudent to limit or avoid exposure to vasoconstrictors, if
extended pain control is necessary. Where I :200,000 or possible.These include poorly controlled American Society
I :300,000epinephrine is availablewith lidocaine,these con­ of Anesthesiologists Physical Status classification system
centrations are preferred for pain control.3° (ASA) 3 and all ASA 4 and greater cardiovascular risk
The dosagesin Table 3-5 represent recommended maxi­ patients. However,as stated, the risk of epinephrine admin­
mums as suggested by this author and others.31They are istration must be weighed against the benefits to be gained
conservativefiguresbut still provide the dental practitioner
with adequatevolumesto produce clinicallyacceptableanes­
thesia. The American Heart Association as far back as 1964
stated that "the typical concentrations of vasoconstrictors TABLE 3-6
contained in local anesthetics are not contraindicated in Means of Maximum Changes from Baseline for Blood
patients with cardiovascular disease so long as preliminary Pressure and Heart Rate*
aspiration is practiced, the agent is injected slowly,and the
max A max A max A
smallest effectivedose is administered."32In 1954 the New SBP,mm DBP,mm HR, bpm
Hypertensives
Anesthesia with 15.3 2.3 9.3
epinephrine
TABLE 3-5
Anesthesia without 11.7 3.3 4.7
Recommended Maximum Dosages of Epinephrine epinephrine
CARTRIDGES (ROUNDED OFF) Normotensives
Normal, Patient With Clinically Anesthesia with 5.0 -0.7 6.3
Epinephrine Healthy Significant epinephrine
Concentration Patient Cardiovascular Disease Anesthesia without 5.0 4.0 0.7
(µg/Cartridge) (ASA I)* (ASA Ill or IV)t epinephrine*

1: 50,000 (36) 5.5 Data from Cardiovasculareffectsof epinephrine in hypertensivedental


1: 100,000(18) ll:j: 2 patients: summary, evidence report/technology assessmentnumber 48.
22:j: AHRQ Publication Number 02-EOOS,Rockville,Md. March 2002,Agency
1:200,000 (9) 4
for Healthcare Researchand Quality.Availableat: http://www.ahrq.gov/
*Maximum epinephrine dose of 0.2 mg or 200 µg per appointment. clinic/epcsums/ephypsum.htm
t Maximum recommended dose of 0.04 or 40 µg per appointment. DBP, Diastolicblood pressure; HR, heart rate; SBP, systolicblood
:j:Actualmaximum volume of administration is limited by the dosage of pressure.
local anesthetic drug. *Unweightedmean of subject means reported in three studies.

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CHAPTER3 Pharmacology of Vasoconstrictors 45

from its inclusion in the local anesthetic solution. Can Mode of Action. The actions of norepinephrine are almost
clinically adequate pain control be provided for this patient exclusivelyon a. receptors (90%). It also stimulates P actions
without a vasoconstrictor in the solution? What is the in the heart (10%). Norepinephrine is one fourth as potent
potential negative effect of poor anesthesia on endogenous as epinephrine.
release of catecholamines in response to sudden, unexpected
pain? Systemic Actions
The use of vasoconstrictors for cardiovascularly compro­ Myocardium. Norepinephrine has a positive inotropic
mised patients is reviewed in greater depth in Chapter 20. action on the myocardium through p1 stimulation.
Hemostasis. Epinephrine-containing local anesthetic Pacemaker Cells. Norepinephrine stimulates pacemaker
solutions are used, via infiltration into the surgical site, to cellsand increasestheir irritability,leading to a greater inci­
prevent or to minimize hemorrhage during surgical and dence of cardiac dysrhythmias CP1 action).
other procedures. The 1:50,000 dilution of epinephrine is Coronary Arteries. Norepinephrine produces an increase
more effectivein this regardthan lessconcentrated 1: 100,000 in coronary artery blood flowthrough a vasodilatory effect.
or 1:200,000solutions.36 Epinephrine dilutions of 1:50,000 Heart Rate. Norepinephrine produces a decrease in
and 1: 100,000are considerablymore effectivein restricting heart rate caused by reflexactions of the carotid and aortic
surgical blood loss than are local anesthetics without vaso­ baroreceptors and the vagusnerve after a marked increasein
constrictor additives.26 both systolicand diastolicpressures.
Clinical experience has shown that effectivehemostasis Blood Pressure. Both systolicand diastolicpressures are
can be obtained with concentrations of 1: 100,000epineph­ increased,systolicto a greater extent. This effectis produced
rine. Although the small volume of 1:50,000 epinephrine through the a-stimulating actions of norepinephrine, which
required for hemostasis does not increase a patient's risk, lead to peripheral vasoconstriction and a concomitant
consideration alwaysshould be givento use of the 1: 100,000 increase in peripheral vascular resistance.
dilution, especiallyin patients known to be more sensitiveto Cardiovascular Dynamics. The overallaction of norepi­
catecholamines.These include hyperresponders on the Bell­ nephrine on the heart and cardiovascular system is as
shaped curve, as well as ASA 3 or 4 risk cardiovascularly follows:
compromised individuals and geriatric patients. • Increased systolicpressure
• Increased diastolic pressure
• Decreasedheart rate
Norepinephrine (Levarterenol) • Unchanged or slightlydecreased cardiac output
Proprietary Names. Levophed, Noradrenalin; levarterenol • Increased stroke volume
is the officialname of norepinephrine. • Increased total peripheral resistance
Vasculature. Norepinephrine, through a. stimulation,
Chemical Structure. Norepinephrine (as the bitartrate) in produces constriction of cutaneous blood vessels.This leads
dental cartridgesis relativelystablein acid solutions, deterio­ to increasedtotal peripheral resistanceand increasedsystolic
rating on exposure to light and air. The shelf life of a car­ and diastolicblood pressures.
tridge containing norepinephrine bitartrate is 18 months. The degree and duration of ischemia noted after norepi­
Acetone-sodium bisulfite is added to the cartridge to retard nephrine infiltration into the palate have led to soft tissue
deterioration. necrosis (Fig.3-1).

Source. Norepinephrine is available in both synthetic and


natural forms. The natural form constitutes approximately
20%of the catecholamineproduction of the adrenalmedulla.
In patients with pheochromocytoma, a tumor of the adrenal
medulla, norepinephrine may account for up to 80% of
adrenal medullary secretions. It exists in both levorotatory
and dextrorotatory forms; the levorotatory form is 40 times
as potent as the dextrorotatory form. Norepinephrine is syn­
thesized and is stored at postganglionic adrenergic nerve Figure 3-1. Sterile abscesson the palate produced by excessive
terminals. use of a vasoconstrictor (norepinephrine).

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46 PART I The Drugs

Respiratory System. Norepinephrine does not relax norepinephrine be eliminated as a vasoconstrictor in dental
bronchial smooth muscle, as does epinephrine. It does, local anesthetics,a statement with which this author whole­
however,produce a-induced constriction of lung arterioles, heartedly agrees.30
which reduces airway resistance to a small degree. Norepi­ Normal healthy patient: 0.34 mg per appointment; 10 mL
nephrine is not clinically effectivein the management of of a 1:30,000solution
bronchospasm. Patient with clinically significant cardiovascular disease (ASA
Central Nervous System. Similar to epinephrine, nor­ 3 or 4): 0.14 mg per appointment; approximately4 mL
epinephrine does not exhibit CNS-stimulating actions at of a 1:30,000solution
usual therapeutic doses; its CNS-stimulating properties are
most prominent after overdose. Clinical manifestations are
similar to those of epinephrine overdose (p. 43) but are less Levonordefrin
frequent and usually are not as severe. Proprietary Name. Neo-Cobefrin.
Metabolism. Norepinephrine increases the basal meta­
bolic rate. Tissue oxygen consumption is also increased in Chemical Structure. Levonordefrinis freelysolublein dilute
the area of injection. Norepinephrine produces an elevation acidic solutions. Sodium bisulfiteis added to the solution to
in the blood sugar levelin the same manner as epinephrine, delayits deterioration. The shelflifeof a cartridge containing
but to a lesser degree. levonordefrin-sodium bisulfite is 18 months.
Termination of Action and Elimination. The action of
norepinephrine is terminated through its reuptake at adren­ Source. Levonordefrin, a synthetic vasoconstrictor, is pre­
ergic nerve terminals and its oxidation by MAO.Exogenous pared by the resolution of nordefrin into its optically
norepinephrine is inactivated by COMT. active isomers. The dextrorotatory form of nordefrin is
Side Effects and Overdose. Clinical manifestations of virtually inert.
norepinephrine overdose are similar to but less frequent
and less severe than those of epinephrine. They normally
involveCNS stimulation. Excessivelevelsof norepinephrine HXf9H
~ CH3H
I H-CH-NH
I I
in the blood produce markedlyelevatedsystolicand diastolic
pressures with increased risk of hemorrhagic stroke, head­ H ::::::,...
ache, angina! episodes in susceptible patients, and cardiac
dysrhythmias.
Extravascular injection of norepinephrine into tissues Mode of Action. It appears to act through direct a. receptor
may produce necrosis and sloughing because of intense stimulation (75%)with some 13 activity(25%), but to a lesser
a. stimulation. In the oral cavity, the most likely site degree than epinephrine. Levonordefrin is 15% as potent a
to encounter this phenomenon is the hard palate (see vasopressor as epinephrine.
Fig. 3-1). Norepinephrine should be avoided for vaso­
constricting purposes (e.g., hemostasis), especially on the Systemic Actions. Levonordefrinproduces less cardiac and
palate.An increasingnumber of authorities have stated that CNS stimulation than is produced by epinephrine.
norepinephrine should not be used at all with local Myocardium. The same action as epinephrine is seen,
anesthetics.30•37 but to a lesser degree.
Clinical Applications. Norepinephrine is used as a vaso­ Pacemaker Cells. The same action as epinephrine is
constrictor in local anesthetics and for the management of seen, but to a lesser degree.
hypotension. Coronary Arteries. The same action as epinephrine is
Availability in Dentistry. In the United States, norepi­ seen, but to a lesser degree.
nephrine is no longer availablein local anesthetic solutions Heart Rate. The same action as epinephrine is seen, but
used in dentistry. In the past, it was included with the local to a lesser degree.
anesthetics propoxycaine and procaine in a 1:30,000 con­ Vasculature. The same action as epinephrine is seen,but
centration. In other countries, norepinephrine is included to a lesser degree.
withlidocaine (Germany) andmepivacaine (Germany) or as Respiratory System. Some bronchodilation occurs, but
the combination of norepinephrine and epinephrine with to a much smaller degree than with epinephrine.
lidocaine (Germany) or tolycaine (Japan).21 Central Nervous System. The same action as epineph­
Maximum Doses. When given, norepinephrine should rine is seen, but to a lesser degree.
be used for pain control only,there being no justification for Metabolism. The same action as epinephrine is seen,but
its use in obtaining hemostasis. It is approximately 25% as to a lesser degree.
potent a vasopressor as epinephrine and therefore is used Termination of Action and Elimination. Levonordefrin
clinicallyas a 1:30,000dilution. is eliminated through the actions of COMT and MAO.
Recommendations of the International Federation of Side Effects and Overdose. These are the same as with
Dental Anesthesiology Societies (IFDAS) suggest that epinephrine, but to a lesser extent. With higher doses,

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CHAPTER3 Pharmacology of Vasoconstrictors 47

additional side effects include hypertension, ventricular dysrhythmias are rarely noted, even after large doses of
tachycardia, and anginal episodes in patients with coronary phenylephrine.
artery insufficiency. Cardiovascular Dynamics. Overall, the cardiovascular
Clinical Applications. Levonordefrin is used as a vaso­ actions of phenylephrine are as follows:
constrictor in local anesthetics. • Increased systolicand diastolic pressures
Availability in Dentistry. It can be obtained with mepi­ • Reflexbradycardia
vacaine in a 1:20,000dilution. • Slightlydecreased cardiac output (resulting from
Maximum Doses. Levonordefrinis considered one sixth increased blood pressure and bradycardia)
(15%) as effectivea vasopressor as epinephrine; therefore it • Powerfulvasoconstriction (most vascular beds
is used in a higher concentration (1 :20,000). constricted, peripheral resistanceincreased significantly)
For all patients, the maximum dose should be 1 mg per but without marked venous congestion
appointment; 20 mL of a 1:20,000 dilution (11 • Rarelyassociatedwith provoking cardiac dysrhythmias
cartridges).* Respiratory System. Bronchi are dilated but to a lesser
In the concentration at which it is available,levonordefrin degreethan with epinephrine. Phenylephrine is not effective
has the same effect on the clinical activity of local anes­ in treating bronchospasm.
thetics as does epinephrine in 1:50,000 or 1: 100,000 Central Nervous System. A minimum effect on CNS
concentration. activity is noted.
Metabolism. Some increase in the metabolic rate is
noted. Other actions (e.g., glycogenolysis)are similar to
Phenylephrine Hydrochloride those produced by epinephrine.
Proprietary Name. Neo-Synephrine. Termination of Action and Elimination. Phenylephrine
undergoes hydroxylation to epinephrine, then oxidation to
Chemical Structure. Phenylephrineis quite solublein water. metanephrine, after which it is eliminated in the same
It isthe most stableand the weakestvasoconstrictoremployed manner as epinephrine.
in dentistry. Side Effects and Overdose. CNS effects are minimal
with phenylephrine.Headacheand ventricular dysrhythmias
have been noted after overdose. Tachyphylaxisis observed
with long-term use.
Clinical Applications. Phenylephrine is used as a vaso­
constrictor in localanesthetics,for the management of hypo­
tension, as a nasal decongestant,and in ophthalmic solutions
to produce mydriasis.
Availability in Dentistry. Phenylephrine was used with
Source. Phenylephrine is a synthetic sympathomimetic 4% procaine in a 1:2500 dilution (no longer available in
amine. dental cartridges).
Maximum Doses. Phenylephrine is considered only one
Mode of Action. Direct a receptor stimulation occurs twentieth as potent as epinephrine, hence its use in a 1:2500
(95%). Although the effect is less than with epinephrine, dilution (equivalent to a 1:50,000 epinephrine concentra­
duration is longer.Phenylephrine exertslittle or no p action tion). It is an excellentvasoconstrictor,with few significant
on the heart. Only a smallportion of its activityresults from side effects.
its ability to release norepinephrine. Phenylephrine is only Normal healthy patient: 4 mg per appointment; 10 mL of a
5% as potent as epinephrine. 1:2500 solution
Patient with clinically significant cardiovascular impairment
Systemic Actions (ASA 3 or 4): 1.6 mg per appointment, equivalent to
Myocardium. It has little chronotropic or inotropic 4 mL of a 1:2500 solution
effecton the heart.
Pacemaker Cells. Little effectis noted.
Coronary Arteries. Increased blood flow occurs as the Felypressin
result of dilation. Proprietary Name. Octapressin.
Blood Pressure. a action produces increasesin both sys­
tolic and diastolic pressures. Chemical Structure
Heart Rate. Bradycardiais produced by reflexactions of
the carotid-aortic baroreceptorsand the vagusnerve.Cardiac

*Maximum volume for administration may be limited by the dose of the Cys-Phe-Phe-Gly-Asn-Cys-Pro-Lys-GlyNH2
local anesthetic.

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48 PARTI The Drugs

Source. Felypressinis a synthetic analog of the antidiuretic for postoperative pain control, and the medical status of the
hormone vasopressin. It is a nonsympathomimetic amine, patient.
categorizedas a vasoconstrictor.
Length of the Dental Procedure
Mode of Action. Felypressin acts as a direct stimulant The addition of any vasoactive drug to a local anesthetic
of vascular smooth muscle. Its actions appear to be prolongs the duration (and depth) of pulpal and soft tissue
more pronounced on the venous than on the arteriolar anesthesiaof most localanesthetics.For example,pulpal and
microcirculation.38 hard tissue anesthesiawith 2% lidocaine lasts approximately
10 minutes; the addition of 1:50,000, 1:80,000, 1: 100,000,
Systemic Actions or 1:200,000epinephrine increasesthis to approximately60
Myocardium. No direct effectsare noted. minutes. The addition of a vasoconstrictor to prilocaine, on
Pacemaker Cells. Felypressinis nondysrhythmogenic,in the other hand, does not significantlyincrease the duration
contrast to the sympathomimetic amines (e.g.,epinephrine, of clinicallyeffectivepain control. Prilocaine 4%, after nerve
norepinephrine). block injection, provides pulpal anesthesiaof about 40 to 60
Coronary Arteries. When administered in high doses minutes' duration. (Infiltration injection with prilocaine 4%
(greaterthan therapeutic), it may impair blood flowthrough provides approximately 10to 15 minutes of pulpal anesthe­
the coronary arteries. sia.) The addition of a 1:200,000epinephrine concentration
Vasculature. In high doses (greater than therapeutic), to prilocaine increases this slightly (to about 60 to 90
felypressin-inducedconstriction of cutaneous blood vessels minutes).41
may produce facialpallor. Averagedurations of pulpal and hard tissue anesthesia
Central Nervous System. Felypressinhas no effect on expected from commonly used local anesthetics with and
adrenergic nerve transmission; thus it may be safelyadmin­ without vasoconstrictors are shown in Table3-7.
istered to hyperthyroid patients and to anyone receiving The typical dental patient is scheduled for a I-hour
MAO inhibitors or tricyclicantidepressants. appointment. The duration of actual treatment (and the
Uterus. It has both antidiuretic and oxytocicactions, the desirable duration of profound pulpal anesthesia) is 47.9
latter contraindicating its use in pregnant patients. minutes (standard deviation [SD] 14.7minutes) in a general
Side Effects and Overdose. Laboratory and clinical dentistry office,whereas in the officesof dental specialists,
studies with felypressinin animals and humans have dem­ treatment time is 39.1 minutes (SD 19.4minutes).42
onstrated a widemargin of safety.39 The drug iswelltolerated For routine restorativeprocedures, it might be estimated
by the tissues into which it is deposited,with little irritation that pulpal anesthesiawill be required for approximately40
developing.The incidence of systemicreactions to felypres­ to 50 minutes. As can be seen in Table 3-7, it is difficult to
sin is minimal. achieveconsistentlyreliablepulpal anesthesiawithout inclu­
Clinical Applications. Felypressinis used as a vasocon­ sion of a vasoconstrictor (seeminutes marked with asterisks
strictor in local anesthetics to decreasetheir absorption and in Table3-7).
increase their duration of action.
Availability in Dentistry. Felypressinis employed in a
dilution of 0.03 IU/mL (International Units) with 3% prilo­ TABLE 3-7
caine in Japan, Germany,and other countries. It is not avail­ Average Durations of Pulpal and Hard
able as a vasoconstrictor in local anesthetics in North Tissue Anesthesia
America.
Infiltration. Nerve Block,
Maximum Doses. Felypressin-containing solutions are
Local Anesthetic minutes minutes
not recommended for use where hemostasis is necessary
because of its predominant effecton the venous rather than Lidocaine HCL
2%- no vasoconstrictor 5-10* =10-20*
the arterial circulation.40
For patients with clinically significant cardiovascular
2% +epinephrine 1:50,000 "'60 zso
2% + epinephrine 1: 100,000 =60 :?:60
impairment (ASA 3 or 4), the maximum recommended
2% +epinephrine 1:200,000 "'60 ~60
dose is 0.27 IU; 9 mL of 0.03 IU/mL. Mepivacaine HCL
3% - no vasoconstrictor 5-10* 20-40*
2% + levonordefrin 1:20,000 ~60 zso
SELECTION OF A VASOCONSTRICTOR 2% + epinephrine 1: 100,000 ~60 ~60
Prilocaine HCL
Two vasoconstrictors are availablein local anesthetic solu­ 4% - no vasoconstrictor 10-15* 40-60*
tions in North America: epinephrine and levonordefrin. 4% + epinephrine 1:200,000 ~o 60-90
In the selection of an appropriate vasoconstrictor,if any, Articaine HCL
for use with a local anesthetic, severalfactors must be con­ 4% + epinephrine 1: 100,000 ~60 :?:60
sidered: the length of the dental procedure, the need for *Indicatesduration of pulpal anesthesia usually inadequate to provide
hemostasis during and after the procedure, the requirement pain control for a typical 48-minute procedure.

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CHAPTER 3 Pharmacology of Vasoconstrictors 49

• Patients with certain noncardiovascular diseases(e.g.,


Requirement for Hemostasis thyroid dysfunction, diabetes, sulfite sensitivity)
Epinephrine is effectivein preventing or minimizing blood • Patients receivingMAO inhibitors, tricyclic
loss during surgical procedures. However,epinephrine also antidepressants, and phenothiazines
produces a rebound vasodilatory effect as the tissue level In each of these situations,it is necessaryto determine the
of epinephrine declines. This leads to possible bleeding degree of severity of the underlying disorder to determine
postoperatively, which potentially interferes with wound whether a vasoconstrictor may be safelyincluded or should
healing.26 be excluded from the local anesthetic solution. It is not
Epinephrine, which possessesboth exand P actions, pro­ uncommon for medical consultation to be sought to aid in
duces vasoconstriction through its ex effects. Used in a determining this information.
1:50,000 concentration, and even at 1: 100,000 (but to a Management of these patients is discussed in depth in
lesser extent), epinephrine produces a definite rebound P Chapters 10 and 20. Briefly,however,it may be stated that
effect once ex-induced vasoconstriction has ceased. This local anesthetics with vasoconstrictors are not absolutely
leads to increasedpostoperative blood loss,which, if signifi­ contraindicated for the patient whose medical condition has
cant (not usuallythe case in dentistry), could compromise a been diagnosed and is under control through medical or
patient's cardiovascularstatus. surgical means (ASA2 or 3 risk), and if the vasoconstrictor
Phenylephrine, a longer-acting,almost pure ex-stimulating is administered slowly,in minimal doses,after negativeaspi­
vasoconstrictor,does not produce a rebound p effectbecause ration has been ensured.
its P actions are minimal. Therefore because it is not as Patients with a resting blood pressure (minimum
potent a vasoconstrictor as epinephrine, hemostasis during 5-minute rest) of greater than 200 mm Hg systolicor greater
the procedure is not as effective;however,becauseof the long than 115mm Hg diastolic should not receiveelectivedental
duration of action of phenylephrine compared with that of care until their more significant medical problem of high
epinephrine, the postoperativeperiod passeswith lessbleed­ blood pressure is corrected. Patients with severe car­
ing. Total blood loss is usuallylower when phenylephrine is diovascular disease (ASA3 or 4 risk) may be at too great a
used. Phenylephrine is not included in any dental local anes­ risk for elective dental therapy, for example, a patient
thetic formulation. who has had a recent (within the past 6 months) acute
Norepinephrine is a potent exstimulator and vasoconstric­ myocardial infarction with significant myocardial damage;
tor that has produced documented cases of tissue necrosis a patient who has been experiencing anginal episodes at
and sloughing.Norepinephrine cannot be recommended as rest on a daily basis, or whose signs and symptoms are
a vasoconstrictor in dentistry because its disadvantagesout­ increasing in severity (preinfarction or unstable angina);
weigh its advantages.Other more or equally effectivevaso­ or a patient whose cardiac dysrhythmias are refractory
constrictorsareavailablethat do not possessthe disadvantages to antiarrhythmic drug therapy.45 Epinephrine and other
of norepinephrine.v'" vasoconstrictors can be administered, within limits, to
Felypressin constricts the venous circulation more than patients with mild to moderate cardiovascular disease
the arteriolar circulation and therefore is of minimal value (ASA 2 or 3). Because felypressin has minimum cardio­
for hemostasis. vascular stimulatory action and is nondysrhythmogenic,
Vasoconstrictorsmust be deposited locallyinto the surgi­ it is the recommended drug for the ASA3 or 4 cardiovascular
cal site (area of bleeding) to provide hemostasis. They act risk patient. Epinephrine also is contraindicated in patients
directlyon exreceptors in the vascular smooth muscle. Only exhibiting clinical evidence of the hyperthyroid state."
small volumes of local anesthetic solutions with vasocon­ Signs and symptoms include exophthalmos, hyperhidrosis,
strictor are required to achievehemostasis (i.e.,just enough tremor, irritability and nervousness, increased body tem­
to produce ischemia at the site). perature, inability to tolerate heat, increased heart rate,
and increased blood pressure. Minimal dosages of epine­
phrine are recommended as a vasoconstrictor during
Medical Status of the Patient general anesthesia when a patient (in any ASAcategory) is
Fewcontraindications are known to vasoconstrictor admin­ receiving a halogenated anesthetic (halothane, isotlurane,
istration in the concentrations in which they are found in sevotlurane, or entlurane). These inhalation (general) anes­
dental local anesthetics. For all patients, and for some in thetics sensitize the myocardium such that epinephrine
particular, the benefits and risks of including the vasopressor administration is frequently associatedwith the occurrence
in the local anesthetic solution must be weighed against the of ventricular dysrhythmias (PVCs or ventricular fibrilla­
benefits and risks of using a plain anesthetic solution.":" In tion). Felypressin is recommended in these situations;
general,these groups consist of the following: however,becauseof its potential oxytocicactions,felypressin
• Patients with more significant cardiovasculardisease is not recommended for pregnant patients. Once the
(ASA3 and 4)* impaired medical status of the patient is improved (e.g.,ASA
4 becomesASA3), routine dental care involvingthe admin­
*The ASA Physical Status Classification System is discussed in depth in istration of local anesthetics with vasoconstrictors is
Chapter 10. indicated.

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50 PARTI The Drugs

Patients being treated with MAO inhibitors may receive 6. Myers RR,Heckman HM: Effectsof local anesthesia on nerve
vasoconstrictors within the usual dental dosage parameters blood flow:studies using lidocainewith and without epineph­
without increasedrisk.47'48 Patients receivingtricyclicantide­ rine, Anesthesiology71:757-762, 1989.
pressants are at greater risk for the developmentof dysrhyth­ 7. Ahlquist RP: A study of adrenotropic receptors,Am J Physiol
153:586-600,1948.
mias with epinephrine administration. It is recommended
8. Hieble JP: Adrenoceptor subclassification: an approach to
that when epinephrine is administered to these patients, its
improved cardiovasculartherapeutics, Pharmaceut ActaHelvet
dose be minimal. Administration of levonordefrin or nor­ 74:63-71, 2000.
epinephrine is absolutelycontraindicated in patients receiv­ 9. SmileyRM, KwatraMM, Schwinn DA:New developments in
ing tricyclicantidepressants.49 Largedosesof vasoconstrictor cardiovascular adrenergic receptor pharmacology: molecular
may induce severe (exaggerated)responses. mechanisms and clinicalrelevance,J Cardiothorac VaseAnesth
Local anesthetic formulations with vasoconstrictors also 12:10-95, 1998.
contain an antioxidant (to delay oxidation of the vasocon­ 10. Braun H: Uber den Einfluss der Vitalitat der Gewebe auf die
strictor). Sodium bisulfite is the most frequently used anti­ ortlichen und allgemeinenGiftwirkungenlocalabaesthesieren­
oxidant in dental cartridges. It prolongs the shelf life of the der Mittel, und uber die Bedeutung des Adrerenalins fur die
anesthetic solution with vasoconstrictorto approximately18 Lokalanasthesie,Arch Klin Chir 69:541-591, 1903.
11. Tolas AG, Pflug AE, Halter JB: Arterial plasma epinephrine
months. However,sodium bisulfite renders the local anes­
concentrations and hemodynarnicresponsesafter dental injec­
thetic considerably more acidic than the same solution
tion of local anesthetic with epinephrine, J Am Dent Assoc
without a vasoconstrictor.Acidicsolutions oflocal anesthet­ 104:41--43,1982.
ics contain a greater proportion of charged cation molecules 12. JastakJT,YagielaJA,Donaldson D, editors: Localanesthesia of
(RNH+)than of uncharged base molecules (RN). Becauseof the oral cavity,Philadelphia, 1995,WB Saunders.
this, diffusion of the local anesthetic solution into the axo­ 13. Holroyd SV,Requa-Clark B: Local anesthetics. In Holroyd SV,
plasm is slower,resulting in (slightly)delayedonset of anes­ Wynn RL, editors: Clinical pharmacology in dental practice,
thesia when local anesthetics containing sodium bisulfite ed 3, St Louis, 1983,Mosby.
(and vasoconstrictors) are injected. 14. Malamed SF: Handbook of local anesthesia, ed 5, St Louis,
Vasoconstrictors are important additions to local anes­ 2004,Mosby.
thetic solutions. Numerous studies have demonstrated 15. Cryer PE:Physiologyand pathophysiologyof the human sym­
pathoadrenal neuroendocrine system,N Engl J Med 303:436--
conclusively that epinephrine, when added to short- or
444, 1980.
medium-duration local anesthetic solutions, slowsthe rate
16. YagielaJA: Epinephrine and the compromised heart, Orofac
of absorption, lowersthe systemicblood level,delayscresting Pain Manage 1:5-8, 1991.
of the peak blood level,prolongs the duration of anesthesia, 17. KanekoY,Ichinohe T, Sakurai M, et al: Relationship between
intensifiesthe depth of anesthesia,and reducesthe incidence changesin circulation due to epinephrine oral injection and its
of systemicreactions.18 In modern dentistry, adequate pain plasma concentration, Anesth Prog 36:188-190, 1989.
control of sufficient clinical duration and depth is difficult 18. de Jong RH: Uptake, distribution, and elimination. In de Jong
to achievewithout inclusion of vasoconstrictors in the local RH, editor: Local anesthetics,St Louis, 1994,Mosby.
anesthetic solution. Unless specificallycontraindicated by a 19. Huang KC:Effectof intravenous epinephrine on heart rate as
patient's medical status (ASA4 or above) or by the required monitored with a computerized tachometer, Anesthesiology
duration of treatment (short), inclusion of a vasoconstrictor 73:A762,1990.
20. Narchi P,Mazoit J-X,Cohen S,SamiiK:Heart rate response to
should be considered routinely.When these drugs are used,
an IV test dose of adrenaline and lignocaine with and without
however, care always must be taken to avoid unintended
atropine pretreatment, Br J Anaesth 66:583-586, 1991.
intravascular administration of the vasoconstrictor (as well 21. Malamed SF,SykesP,KubotaY,et al:Localanesthesia:a review,
as the local anesthetic) through multiple aspirations and Anesth Pain Control Dent 1:11-24, 1992.
slowadministration of minimum concentrations of both the 22. Lipp M, Dick W, Daublander M: Examination of the central
vasoconstrictor and the local anesthetic. venous epinephrine level during local dental infiltration and
block anesthesiausing tritium marked epinephrine as vasocon­
References strictor, Anesthesiology69:371,1988.
1. Moore PA, Hersh EV: Local anesthetics: pharmacology and 23. Stanton-Hicks M, BergesPU, Bonica JJ: Circulatory effectsof
toxicity,Dent Clin North Am 54:587-599,2010. peridural block. IV.Comparison of the effectsof epinephrine
2. Finder RL,Moore PA:Adversedrug reactions to local anesthe­ and phenylephrine,Anesthesiology39:308-314, 1973.
sia, Dent Clin North Am 46:447--457,2002. 24. Robertson VJ, Taylor SE, Gage TW: Quantitative and qualita­
3. Brown G: The influenceof adrenaline,noradrenaline vasocon­ tive analysisof the pressor effectsof levonordefrin,J Cardiovasc
strictors on the efficacyof lidocaine, J Oral Ther Pharmacol Pharmacol 6:529-935, 1984.
4:398--405,1968. 25. Clutter WE, Bier DM, Shah SD,Cryer PE:Epinephrine plasma
4. Cowan A: Further clinical evaluation of prilocaine (Citanest), metabolic clearancerates and physiologicthresholds for meta­
with and without epinephrine, Oral SurgOral Med Oral Pathol bolic and hemodynarnic actions in man, J Clin Invest 66:94-
26:304-311, 1968. 101, 1980.
5. Carpenter RL, Kopacz DJ, Mackey DC: Accuracy of Doppler 26. Sveen K: Effect of the addition of a vasoconstrictor to local
capillary flow measurements for predicting blood loss from anesthetic solution on operative and postoperative bleeding,
skin incisions in pigs,Anesth Analg 68:308-311, 1989. analgesia,and wound healing,Int J Oral Surg 8:301-306, 1979.

www.ShayanNemoodar.com
CHAPTER 3 Pharmacology of Vasoconstrictors 51

27. Meechan JG: The effects of dental local anaesthetics on blood 38. Altura BM, Hershey SG, ZweifachBW:Effects of a synthetic
glucose concentration in healthy volunteers and in patients analogue of vasopressin on vascular smooth muscle, Proc Soc
having third molar surgery, Br Dent J 170:373-376, 1991. Exp BiolMed 119:258-261,1965.
28. Lefkowitz RJ, Hoffman BB, Taylor P: Neurohumoral transmis­ 39. Sunada K, Nakamura K, Yamashiro M, et al: Clinically safe
sion: the autonomic and somatic motor nervous system. dosage of felypressinfor patients with essential hypertension,
In Brunton LL, Lazo JS, Parker KL editors: Goodman and Anesth Prog 43:408--415,1996.
Gilman's the pharmacological basis of therapeutics, ed 11, 40. Newcomb GM, Waite IM: The effectivenessof local analgesic
New York, 2006, McGraw-Hill Companies. preparations in reducing haemorrhage during periodontal
29. Campbell RL: Cardiovascular effects of epinephrine overdose: surgery,J Dent 1:37-42, 1972.
case report, Anesth Prog 24:190-193, 1977. 41. Epstein S: Clinical study of prilocaine with varying con­
30. Jakob W: Local anaesthesia and vasoconstrictive additional centrations of epinephrine, J Am Dent Assoc 78:85-90,
components, Newslett Int Fed Dent Anesthesiol Soc 2:1, 1989. 1969.
31. Bennett CR: Monheim's local anesthesia and pain control in 42. American Dental Association:2009 survey of dental practice,
dental practice, ed 7, St Louis, 1983, Mosby. Chicago,February 2010,American Dental Association.
32. Management of dental problems in patients with cardiovascu­ 43. van der Bijl P, Victor AM: Adverse reactions associated with
lar disease: report of a working conference jointly sponsored norepinephrine in dental local anesthesia,Anesth Prog 39:37-
by the American Dental Association and American Heart Asso­ 89, 1992.
ciation, J Am Dent Assoc 68:333-342, 1964. 44. Hirota Y,Hori T, Kay K, Matsuura H: Effectsof epinephrine
33. Use of epinephrine in connection with procaine in dental pro­ and norepinephrine contained in 2% lidocaine on hemody­
cedures: report of the Special Committee of the New York namics of the carotid and cerebral circulation in older and
Heart Association, Inc., on the use of epinephrine in connec­ younger adults, Anesth Pain Control Dent 1:343-351,1992.
tion with procaine in dental procedures, J Am Dent Assoc 45. Goulet JP,Perusse R, Turcotte JY:Contraindications to vaso­
50:108, 1955. constrictors in dentistry. Part I. Cardiovascular diseases,Oral
34. Kaplan EL, editor: Cardiovascular disease in dental practice, Surg Oral Med Oral Pathol 74:579--686,1992.
Dallas, 1986, American Heart Association. 46. Goulet JP, Perusse R, Turcotte JY: Contraindications to
35. Cardiovascular effects of epinephrine in hypertensive dental vasoconstrictors in dentistry. Part II. Hyperthyroidism, dia­
patients: summary, evidence report/technology assessment betes, sulfite sensitivity,cortico-dependent asthma, and pheo­
number 48. AHRQ Publication Number 02-E005, March 2002, chromocytoma, Oral Surg Oral Med Oral Pathol 74:587--691,
Agency for Healthcare Research and Quality, Rockville, Md. 1992.
Availableat:http://www.ahrq.gov/clinidepcsums/ephypsum.htm 47. Goulet JP,Perusse R, Turcotte JY:Contraindications to vaso­
36. Buckley JA, Ciancio SG, McMullen JA: Efficacy of epinephrine constrictors in dentistry. Part III. Pharmacologic interactions,
concentration in local anesthesia during periodontal surgery, Oral Surg Oral Med Oral Pathol 74:592--697,1992.
J Periodontol 55:653-657, 1984. 48. VerrillPJ:Adversereactions to local anaestheticsand vasocon­
37. Kaufman E, Garfunkel A, Findler M, et al: Emergencies evolv­ strictor drugs, Practitioner 214:380-387, 1975.
ing from local anesthesia, Refuat Hapeh Vehashinayim 19:13- 49. JastakJT,YagielaJA,Donaldson D, editors: Localanesthesia of
18, 98, 2002. the oral cavity,Philadelphia, 1995,WB Saunders.

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T

Clinical Action
of Specific Agents
' I •I

In the following discussion of the clinical properties of


SELECTION OF A LOCAL ANESTHETIC
specificlocal anesthetic combinations, several concepts are
Although many drugs are classifiedas local anesthetics and presented that require some explanation. These include the
find use within the health professions, only a handful are duration of action of the drug and determination of the
currently used in dentistry.In 1980,when the first edition of maximum recommended dose.
this text was published, five local anesthetics were available
in dental cartridge form in the United States: lidocaine,
mepivacaine, prilocaine, and the combination of procaine
DURATION
and propoxycaine.1 In the years since that first edition, The duration of pulpal (hard tissue) and soft tissue (total)
increased demand for longer-acting local anesthetics led to anesthesia cited for each drug is an approximation. Many
the introduction, in dental cartridges, of bupivacaine (1982 factors affect both the depth and the duration of a drug's
Canada, 1983United States) and etidocaine (1985).In 1975 anesthetic action, prolonging or (much more commonly)
articaine became availablein Germany,and later throughout decreasingit. Thesefactors include but are not limited to the
Europe.Articaine came to North America in 1983(Canada) following:
and to the United Statesin 2000.Articaine is classifiedas an 1. Individual response to the drug (the "bell-shaped"curve)
intermediate-duration local anesthetic. 2. Accuracyin deposition of the local anesthetic
The combination of procaine and propoxycaine was 3. Status of tissues at the site of drug deposition
withdrawn from the U.S.market in January 1996. (vascularity,pH)
As this sixth edition of Handbook of Local Anesthesia 4. Anatomic variation
goes to press, the local anesthetic armamentarium in North 5. Type of injection administered (supraperiosteal
American dentistry includes articaine, bupivacaine, lido­ ["infiltration"] or nerve block)
caine, mepivacaine,and prilocaine. In the subsequent discussionof individual local anesthet­
With the availabilityof these local anesthetics,in various ics, the durations of anesthesia (pulpal and soft tissue) are
combinations with and without vasoconstrictors, it is pos­ presented as a range (e.g.,40 to 60 minutes). This approach
sible for a doctor to select a local anesthetic solution that attempts to take into account the factors mentioned that can
possessesthe specificpain controlling properties necessary influence drug action:
for the patient for any given dental procedure. Table 4-1 1. Normal distribution curve (bell-shaped curve):
lists local anesthetics and the various combinations in Variation in individual response to a drug is common
which they are currently availablein the United States and and expected and is depicted in the so-calledbell or
Canada. Box 4-1 lists these combinations by their expected normal distribution curve (Fig.4-1). Most patients will
duration of clinical action (durations of pulpal and soft respond in a predictable manner to a drug's actions
tissue anesthesia). (e.g.,40 to 60 minutes). However,some patients (with
In this chapter, each of the availablelocal anesthetics in none of the other factors that influence drug action
its various combinations is described.In addition, the ratio­ obviouslypresent) will have a shorter or longer
nale for selection of an appropriate local anesthetic for a duration of anesthesia.This is to be expected and is
given patient at a given appointment is presented. It is entirely normal.
strongly suggestedthat the reader-the potential adminis­ For example,if 100persons are administered an
trator of these drugs-become familiar with this material, appropriate dose of 2% lidocaine HCl with epinephrine
including contraindications to the administration of certain 1: 100,000via supraperiosteal injection over a maxillary
local anesthetic combinations (Table4-2). lateral incisor, and a pulp tester is used to assessthe
52

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CHAPTER4 ClinicalAction of SpecificAgents 53

TABLE 4-1 BOX 4-1 Approximate Duration of Action of


Local Anesthetics Available in North America Local Anesthetics
(August 2011)
Short Duration(PulpalAnesthesiaApproximately
Local Anesthetic 30 Minutes)
(+ Vasoconstrictor) Duration of Action* MepivacaineHCl 3%
Articaine HCl Prilocaine HCl 4% (by infiltration)
4% + epinephrine 1: 100,000 Intermediate
4% + epinephrine 1:200,000 Intermediate IntermediateDuration(PulpalAnesthesiaApproximately
Bupivacaine HCl 60 Minutes)
0.5% + epinephrine 1:200,000 Long Articaine HCl 4% + epinephrine 1: 100,000
Lidocaine HCI Articaine HCl 4% + epinephrine 1:200,000
2% + epinephrine 1:50,000 Intermediate
LidocaineHCl 2% + epinephrine 1:50,000
2% + epinephrine 1: 100,000 Intermediate
LidocaineHCl 2% + epinephrine 1: 100,000
Mepivacaine HCl
3% Short MepivacaineHCl 2% + levonordefrin 1:20,000
2% + levonordefrin 1:20,000 Intermediate Prilocaine HCl 4% (via nerve block only)
Prilocaine HCI Prilocaine HCl 4% + epinephrine 1:200,000
4% Short (infiltration);
intermediate (nerve block) LongDuration(PulpalAnesthesiaApproximately
4% + epinephrine 1:200,000 Intermediate 90+ Minutes)
*The classificationof duration of action is approximate,for extreme
BupivacaineHCl 0.5% + epinephrine 1:200,000 (by
variations may be noted among patients. Short-duration drugs provide nerve block)
pulpal or deep anesthesia for lessthan 30 minutes; intermediate-duration
drugs for about 60 minutes; and long-duration drugs for longer than 90
minutes.

TABLE 4-2
Contraindications for Local Anesthetics
Type of
Medical Problem Drugs to Avoid Contraindication Alternative Drug

Atypicalplasma cholinesterase F.sters Relative Amides


Methemoglobinemia, Prilocaine Relative Other amides or esters
idiopathic or congenital
Significantliver dysfunction Amides Relative Amides or esters,but judiciously
(ASA3--4)
Significantrenal dysfunction Amides or esters Relative Amides or esters,but judiciously
(ASA3--4)
Significantcardiovascular High concentrations of Relative Local anestheticswith epinephrine
disease (ASA3--4} vasoconstrictors (as in racemic concentration of 1:200,000or 1: 100,000,
epinephrine gingivalretraction or mepivacaine 3%, or prilocaine 4%
cords) (nerve blocks)
Clinicalhyperthyroidism High concentrations of Relative Localanesthetics with epinephrine
(ASA3--4) vasoconstrictors (as in racemic concentration of 1:200,000or 1: 100,000,
epinephrine gingivalretraction or mepivacaine 3%, or prilocaine 4%
cords) (nerve blocks)

duration of anesthesia,approximately70% (68.26%) are termed hyperresponders. No dentist complains


will have pulpal anesthesia for approximately60 about these patients because their dental treatment
minutes. These represent the normo-responders. proceeds and is completed with no pain or need for
Approximately15%will have pulpal anesthesia that repeated injection of local anesthetic. However,it is the
lasts beyond the expected 60 minutes-perhaps 70 or final 15%,the hyporesponders, who are well
80 minutes, and even longer for some. These persons remembered by the dentist. These patients, given

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54 PART I The Drugs

34.13% 34.13% TABLE 4-3


Duration of Pulpal Anesthesia by Type of Injection
Infiltration Nerve Block
Local Anesthetic (Minutes) (Minutes)
2.16%
0.11%......_ /0.11% Mepivacaine HO
3%: no vasoconstrictor 5-10 20-40
-3a -2a -1a µ 1a 2a 3a Prilocaine HCl
Figure 4-1. "Bell-shaped"curve. 4%: no vasoconstrictor 10-15 40-60
Bupivacaine HCl
0.5% + epinephrine 1:200,000 60 Up to 12hours
lidocaine with epinephrine, are anesthetized for 45
minutes, 30 minutes, 15 minutes, or even less.These are
the patients about whom the doctor states (incorrectly): (e.g.,in sizeand shape of the head or in thickness of
"They metabolize the drug rapidly:'As was mentioned bone) from person to person. The techniques presented
in Chapter 2, metabolism (biotransformation, in subsequent chapters are based on the middle of the
detoxification)has nothing to do with the clinical bell curve,the so-callednormal responders.Anatomic
effectsof a local anesthetic dissipating. The duration of variations awayfrom this "norm" may influencethe
anesthesia is based simply on the way some persons duration of clinicaldrug action. Although most obvious
respond to this drug (or group of drugs). in the mandible (height of the mandibular foramen,
2. Accuracy in administration of the local anesthetic is width of the ramus, thickness of the cortical plate of
another factor that influencesdrug action. Although bone), such variation also may be noted in the maxilla.
not as significantin certain techniques (e.g., Supraperiostealinfiltration, usuallyeffectivein providing
supraperiosteal) or with certain drugs (e.g., articaine), pulpal anesthesiafor all maxillaryteeth, provides a
accuracyin deposition is a major factor in many nerve shorter duration than expectedor an inadequate depth
blocks in which a considerablethickness of soft tissue of anesthesiawhen alveolarbone is more dense than
must be penetrated to accessthe nerve being blocked. usual.Where the zygomaticarch is lower (primarily in
Inferior alveolarnerve block (IANB)is the prime children, but occasionallyin adults), infiltration
example of a technique in which the depth and anesthesiaof the maxillaryfirst and second molars may
duration of anesthesia are greatly influenced by the provide a shorter duration or may even fail to provide
accuracyof injection. Deposition of local anesthetic adequate depth of pulpal anesthesia.In other cases,the
close to the nerve provides greater depth and duration palatal root of maxillarymolars may not be adequately
of anesthesia compared with an anesthetic deposited at anesthetized,even in the presence of normal thickness of
a greater distance from the nerve to be blocked. the buccal alveolarbone, when that root flaresgreatly
3. The status of the tissues into which a local anesthetic toward the midline of the palate. In the mandible, it is
is deposited influencesthe observed duration of stated that supraperiostealinfiltration is not effectivein
anesthetic action. The presence of normal healthy tissue adults because their cortical plate of bone is too thick;
at the site of drug deposition is assumed. Inflammation, however,accordingto the bell-shaped curve, 15%of
infection, or pain (acute or chronic) usually decreases adult patients should have cortical bone that is thinner,
depth and anticipated duration of anesthesia.Increased perhaps allowingmandibular infiltration to be effective.
vascularity at the site of drug deposition results in more The use of articaine HCl by mandibular infiltration in
rapid absorption of the local anesthetic and a decreased adults has been demonstrated to be highly effective(and
duration of anesthesia.This is most notable in areas of is discussedin detail in Chapters 15and 20).3
inflammation and infection but is also a consideration 5. Finally,the duration of clinical anesthesia is influenced
in "normal" anatomy. The recent introduction by the type of injection administered. For all drugs
(February 2011) of buffered local anesthetics promises presented, administration of a nerve block provides a
to help overcomethis negativeeffect of inflammation longer duration of pulpal and soft tissue anesthesiathan
and infection.2 The neck of the mandibular condyle,the is provided by supraperiosteal injection (e.g.,
target for local anesthetic deposition in the Gow-Gates infiltration). This assumes that the recommended
mandibular nerve block, is considerablyless vascular minimum volume of anesthetic is injected. Lessthan
than the target area for the IANB.The expected recommended volumes decreasethe duration of action.
duration of anesthesia for any local anesthetic will be Largerthan recommended doses do not provide
greater in a less vascular region. increased duration. For example,a duration of pulpal
4. Anatomic variation also influences clinical anesthesia. anesthesia of 10 to 15 minutes may be expectedto
The normal anatomy of the maxilla and the mandible is follow supraperiosteal injection with prilocaine 4% (no
described in Chapter 12.The most notable aspect of vasoconstrictor), whereas a 40- to 60-minute duration is
"normal" anatomy is the presence of extremevariation normal followingnerve block (Table4-3).

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CHAPTER4 ClinicalAction of SpecificAgents 55

MAXIMUM DOSES OF LOCAL ANESTHETICS


TABLE 4-4
Doses of local anesthetic drugs are presented in terms of Maximum Recommended Dosages (MRDs) of Local
milligrams of drug per unit of body weight-as milligrams Anesthetics Available in North America
per kilogram (mg/kg) or as milligrams per pound (mg/lb). MANUFACTURER'SAND FDA (MRD)
These numbers, similar to the ones presented for duration,
Local Anesthetic mg/kg mg/lb MRD.mg
reflect estimated values because there is a wide range (the
bell-shaped curve also is seen here) in patient response to Articaine
blood levelsof local anesthetics (or of any drug). With vasoconstrictor 7.0 3.2 None listed
Bupivacaine
For patients whose responsesto anestheticblood levelslie
With vasoconstrictor None listed None listed 90
within the middle of the normal distribution curve, admin­ With vasoconstrictor 2.0 0.9 90
istration of a maximum dosebased on bodyweight produces (Canada)
a local anesthetic blood levelbelow the usual threshold for Lidocaine
an overdose (toxic) reaction. The response observed if an With vasoconstrictor 7.0 3.2 500
overdosereaction occurs at that dose is mild (e.g.,tremor of Mepivacaine
the arms and legs, drowsiness). Patients who are hypo­ No vasoconstrictor 6.6 3.0 400
responders to elevatedlocal anesthetic blood levelsmay not With vasoconstrictor 6.6 3.0 400
experience any adverse reaction until their local anesthetic Prilocaine
blood level is considerably above this "normal" overdose No vasoconstrictor 8.0 3.6 600
threshold. Thesepatients represent little increasedrisk when With vasoconstrictor 8.0 3.6 600
local anesthetics are administered in "usual" dental doses.
CALCULATIONOF MILLIGRAMSOF
However,hyperresponders may demonstrate clinical signs LOCALANESTHETICPERDENTAL
and symptoms of local anesthetic overdose at blood levels CARTRIDGE(1.8 ml CARTRIDGE)
that are considerablylowerthan those normally necessaryto Local Percent x 1.8 ml=
produce such reactions. To increase safety for all patients Anesthetic Concentration mg/ml mg/Cartridge
during administration of local anesthetics,but especiallyin Articaine 4 40 72*
this latter group, one should alwaysminimize drug dosesand Bupivacaine 0.5 5 9
use the smallest clinically effective dose. Recommended Lidocaine 2 20 36
volumes of local anesthetics are presented for each injection Mepivacaine 2 20 36
technique in Chapters 13, 14,and 15. 3 30 54
The maximum recommended dose (MRD) oflocal anes­ Prilocaine 4 40 72
thetics has been modified in this 6th edition. In previous MRD, Maximum recommended dose.
editions, both the manufacturer's recommended dose *Cartridges of some drugs in the United States read, "1.7 mL. each."The
(MRD-m) and the author's recommended dose (MRD-a) actual volume of all local anesthetic cartridges is approximately 1.76mL.
were listed. In some instances, these doses differed.Where
dosesdiffered,those recommended by this author weremore
conservativethan those recommended by the drug's manu­ increased in the presence of decreasedliver function or per­
facturer. In this 6th edition of Local Anesthesia, only MRDs fusion.' Peakplasma local anesthetic blood levelstend to be
that havebeen approvedby the U.S.Food and Drug Admin­ higher and to remain so longer in these situations. The
istration (FDA)are listed (Table4-4). calculated drug dose (based on body weight) should be
Maximum doses are unlikely to be reached in most decreased in all "at risk" individuals. Unfortunately,there is
dental patients, especiallyadults of normal body weight, for no magical formula that can aid in determining the degree
most dental procedures. Two groups of patients, however, of dose reduction for a givenpatient. It is suggestedthat the
represent potentially increased risk from overly high local doctor evaluate each patient's dental care needs and then
anesthetic blood levels: the smaller, lighter-weight (and devisea treatment plan that takes into account that person's
well-behaved) child, and the debilitated elderly individual. requirement for smaller doses of local anesthetic at every
Considerableattention must be givento drug administration treatment appointment.
in these two groups. The maximum recommended dose A point that has come up in several medicolegal situa­
calculated should always be decreased in medically com­ tions relatedto overdosage(OD) oflocal anestheticsinvolves
promised, debilitated, or elderlypersons. the maximum number of milligrams administered and the
Changes in liver function, plasma protein binding, blood effecton the patient. Assume,for example,that the MRD for
volume, and other important physiologic functions influ­ a localanestheticin a givenpatient is 270 mg, and the patient
ence the manner in which local anesthetics are distributed is administered 271 mg. The thinking among laypersons
and biotransformed in the body.4 The net result of these (and, unfortunately, some health care professionals too) is
changesis increased plasma blood levelsof the drug, associ­ that an overdosewill definitelyoccur.However,this may not
ated with increased relative risk of overdose reaction. The be the case. As mentioned, many factors interact to deter­
half-lives of the amide local anesthetics are significantly mine how a patient will respond to a given drug. When the

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56 PARTI The Drugs

BOX 4-2 Calculation of Maximum Dosage and BOX 4-3 Calculation of Maximum Dosage and
Number of Cartridges (Single Drug) Number of Cartridges (Multiple Drugs)
Patient: 22 Years Old, Healthy, Female, 50 kg Patient: 45-kg Female, Healthy
Local Anesthetic: Lidocaine HCI + Epinephrine 1: 100,000 Local Anesthetic: Mepivacaine 2% + Levonordefrin
Lidocaine2% = 36 mg/cartridge 1:20,000
Lidocaine:7.0 mg/kg= 350 mg (MRD) Mepivacaine2% = 36 mg/cartridge
Number of cartridges: 350/36 = =9% Mepivacaine:6.6 mg/kg= 297 mg (MRD)
Patient receives2 cartridges = 72 mg, but anesthesia is
Patient: 40 Years Old, Healthy, Male, 90 kg inadequate.
Local Anesthetic: Articaine HCI +Epinephrine 1:200,000 Doctor wishes to change to articaine 4% + epinephrine
Articaine 4% = 72 mg/cartridge 1: 100,000.
Articaine: 7.0 mg/kg= 630 mg (MRD)
Number of cartridges: 630/72 = =9.0 How Much Articaine Can This Patient Receive?
Articaine 2% = 72 mg/cartridge
Patient: 6 Years Old, Healthy, Male, 20 kg Articaine: 7.0 mg/kg= 315 mg (MRD)
Local Anesthetic: Mepivacaine HCl, No Vasoconstridor Total dose of BOTH local anesthetics should not exceed
Mepivacaine3% = 54 mg/cartridge the lower of the two calculated doses, or 297 mg.
Mepivacaine:6.6 mg/kg= 132mg (MRD) Patient has received72 mg (lidocaine), thus can still
Number of cartridges: 130/54= =2.5 receive225 mg of articaine.
MRD, Maximum recommended dose.
Therefore,225 mg/72 mg per cartridge = =3.0
cartridges of articaine 4% + epinephrine 1: 100,000.
MRD, Maximum recommended dose.

MRD is exceeded,there is no guarantee that an OD will


occur,onlythat there is a greaterlikelihoodof its occurrence.
Indeed, in certain individuals, an OD may be seen with A commonly asked question is this: "How do I determine
dosagesbelow the calculated MRD (hyperresponders to the the dose of each local anesthetic administered in clinical
drug). Another factor in determining whether an OD will situations in which more than one drug is necessary?"The
occur is the time over which the local anesthetic dose was answer is again that no guaranteed formula existsfor deter­
administered. If all 271 mg is administered within a brief mining this number. One method is simply to ensure that
time frame, the resulting local anesthetic blood levelwill be the total dose of both local anesthetics does not exceedthe
greater than in a situation in which the same dose is admin­ lower of the two maximum doses for the individual agents.
istered a little at a time over severalhours. These points are For example, a 45-kg (100-lb) patient receiving4% pri­
discussedin greater detail in Chapter 18. locaine with epinephrine may be given 8.0 mg/kg (3.6 mg/
Box4-2 provides examplesof how to calculatemaximum lb) (or 360 mg) during a 90-minute procedure (the approxi­
dosages and numbers of local anesthetic cartridges to be mate elimination half-life of prilocaine). She receivestwo
administered to various patients. cartridges (144 mg), but anesthesia is inadequate for the
A minor point, but one that has led to some confusion treatment to proceed. As is commonly the case, the doctor
primarily among dental and dental hygiene students, and blames the lack of anesthesia on the anesthetic drug ("I've
also doctors and hygienists in practice, is that labeling got a bad batch oflocal"), not on technique error or unusual
changeson some cartridges of local anestheticsindicate that patient anatomy,as is more likely.The doctor electsto switch
the volume of solution contained in the cartridge is 1.7mL, to lidocaine2% with epinephrine 1: 100,000to provide anes­
not the "traditional" 1.8mL. In actual fact, dental cartridges thesia. How does one determine the maximum dose of lido­
did not alwayscontain 1.8mL of solution. In the late 1990s, caine that may be used?
when articaine was undergoing the FDA approval process, If lidocainewerebeing administered alone to this patient,
the question was asked of its manufacturer: "Can you guar­ its MRD would be 7.0 mg/kg (3.2 mg/lb) or 315 mg.
antee that each and every cartridge contains at least 1.8 mL However, she has already received 144 mg of prilocaine
of solution?" The answer was "No:' Cartridges are filled within the past few minutes. The amount of lidocaine sug­
mechanically,and very slight variation in volume is noted gestedis the smallertotal maximum dose (which in this case
from one cartridge to the next. When asked if the manufac­ is 315 mg [lidocaine] vs. 360 mg [prilocaine]) minus the
turer could guarantee that each and everycartridge contains dose of prilocaine already administered (144 mg), which
at least 1.7mL of solution, the answer was "Yes."In actual permits a dose of 171mg of lidocaine, or about 4.5 car­
fact, the average volume of local anesthetic solution in a tridges, to be administered to this patient (Box4-3).
dental cartridge in the United States is 1.76mL.6 When the It is extremely unlikely that a "bad batch" of local anes­
MRD of a local anesthetic for a givenpatient is calculated,it thetic has been distributed to the doctor. The most common
is advised that a volume of 1.8 mL should be employed. causes for failure to achieve adequate pain control are

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CHAPTER 4 ClinicalAction of SpecificAgents 57

anatomic variation and faulty technique. (However, blaming clinicallyused localanesthetics.Thus a clean (e.g.,bloodless)
failure to obtain adequate pain control on the local anes­ surgical field is more difficult to maintain with procaine
thetic drug serves to soothe the doctor's ego.) because of increased bleeding.
The concept of maximum recommended dose is dis­ Procaine is of importance in the immediate manage­
cussed more fully in Chapter 18. ment of inadvertent intra-arterial (IA) injection of a drug;
Clinically available local anesthetics (the amides: artic­ its vasodilating properties are used to aid in breaking
aine, bupivacaine, lidocaine, mepivacaine, and prilocaine) arteriospasm.7
are discussed in detail here. Esters (procaine and propoxy­ Although not extremelycommon, the incidenceof allergy
caine) are mentioned in passing, more as a matter of histori­ to both procaine and other ester local anesthetics is signifi­
cal interest than of necessity. Agents available for topical cantly greater than to amide local anesthetics.8
application (topical anesthetics) also are discussed. Metabolized in the blood by plasma cholinesterase,pro­
caine does not exhibit increased toxicity in patients with
ESTER-TYPE LOCAL ANESTHETICS hepatic dysfunction.
The maximum recommended dose of procaine, used for
Procaine HCI peripheral nerve blocks, is 1000mg.9
Pertinent Information With a dissociation constant (pl<.)of 9.1, procaine has a
Classification. Ester. slowclinicalonset of anesthesia (6 to 10minutes)-a reason
Chemical Fonnula. 2-Diethylaminoethyl4-aminobenwate for inclusion of propoxycainein the anesthetic cartridge.
hydrochloride.
Propoxycaine HCI
Pertinent Information
Classification. Ester.
Chemical 2-Diethylaminoethyl-4-amino-2-
Formula.
propoxybenzoate hydrochloride.

Prepared by. Alfred Einhorn, 1904-190S.


Potency. 1 (procaine = 1)
Toxicity. 1 (procaine = 1)
Metabolism. Hydrolyzed rapidly in plasma by plasma
pseudocholinesterase.
Excretion. More than 2% unchanged in the urine
(90% as para-aminobenzoic acid [PABA], 8% as Prepared by. Clinton and Laskowski,19S2.
diethylaminoethanol). Potency. 7 to 8 (procaine = 1).
Vasodilating Properties. Produces the greatestvasodila- Toxicity. 7 to 8 (procaine = 1).
tion of all currently used local anesthetics. Metabolism. Hydrolyzedin both plasma and the liver.
pK •. 9.1. Excretion. Via the kidneys;almost entirely hydrolyzed.
pH of Plain Solution. S.Oto 6.S. Vasodilating Properties. Yes,but not as profound as
pH of Vasoconstrictor-Containing Solution. 3.S to S.S. those of procaine.
Onset of Action. 6 to 10 minutes. pKa. Not available.
Effective Dental Concentration. 2% to 4%. pH of Plain Solution. Not available.
Anesthetic Half-Life. 0.1 hour (6 minutes). Onset of Action. Rapid (2 to 3 minutes).
Topical Anesthetic Action. Not in clinically acceptable Effective Dental Concentration. 0.4%.
concentrations. Anesthetic Half-Life. Not available.
Topical Anesthetic Action. Not in clinicallyacceptable
Comments. Procaine HCl, the first syntheticinjectablelocal concentrations.
anesthetic,is no longer availablein North America in dental
cartridges.However,its proprietary name, Novocain,is syn­ Comments. Propoxycainewas combined with procaine in
onymous throughout the world with dental local anesthesia. solution to provide more rapid onset and a more profound
Until 1996,procaine was found in dental cartridges in com­ and longer-lasting anesthesia than could be obtained with
bination with a second ester anesthetic, propoxycaine. procaine alone.Propoxycainewasnot availablealonebecause
Used as the sole local anesthetic agent for pain control in its higher toxicity (seven to eight times that of procaine)
dentistry, as it was from its introduction in 1904 until the limited its usefulnessas a sole agent.
introduction of the amide local anesthetic lidocaine in the
mid-1940s, 2% procaine (plain) provides essentially no Procaine HCI + Propoxycaine HCI
pulpal anesthesia and from lS to 30 minutes of soft tissue Although it is no longer manufactured or available in the
anesthesia.This is a result of its profound vasodilatingprop­ United States, the combination of two ester anesthetics,
erties. Procaine produces the greatest vasodilation of all propoxycaine + procaine, was worthy of consideration for

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58 PARTI The Drugs

inclusion in a dentist's armamentarium of local anesthetics. Metabolism. In the liver, by the microsomal fixed­
It was useful when the amides were absolutely contra­ function oxidases, to monoethylglyceine and xylidide;
indicated (e.g., because of documented allergy [although xylidide is a local anesthetic that is potentially toxic" (see
this is an extremely unlikely occurrence]), or when several Fig.2-3).
amide local anesthetics failed to provide clinicallyadequate Excretion. Via the kidneys; less than 10% unchanged,
anesthesia. Until its removal from the U.S. market in more than 80% various metabolites.
January 1996, the combination of procaine and propoxy­ Vasodilating Properties. Considerably less than those
caine was the only ester local anesthetic availablein dental of procaine; however, greater than those of prilocaine or
cartridge form. mepivacaine.
A dose of 0.4% propoxycaine/2%procaine with 1:20,000 pKa. 7.9.
levonordefrin (United States) or with 1:30,000norepineph­ pH of Plain Solution. 6.5.
rine (Canada) provided approximately40 minutes of pulpal pH of Vasoconstrictor-Containing Solution. =3.5.
anesthesiaand 2 to 3 hours of soft tissue anesthesia.The use Onset of Action. Rapid (3 to 5 minutes).
of norepinephrine in local anesthetic solutions is no longer Effective Dental Concentration. 2%.
recommended, especiallyin areaswhere prolonged ischemia Anesthetic Half-Life. 1.6hours (=90 minutes).
can lead to tissue necrosis. In the oral cavity,this is most Topical Anesthetic Action. Yes(in clinicallyacceptable
likelyto be seen in the palate. concentrations [5%]).
Pregnancy Classification. B.
Maximum Recommended The manufacturer's maxi­
Dose. Safety During Lactation. S.
mum recommended dose was 3.0 mg/lb or 6.6 mg/kg of
body weight for the adult patient." For children, a dose Maximum Recommended Dose. The maximum recom­
of 3.0 mg/lb was recommended up to a maximum of five mended dose by the FDAof lidocaine with or without epi­
cartridges. nephrine is 3.2 mg/lb or 7.0 mg/kg of body weight for the
adult and pediatric patient, not to exceed a an absolute
AMIDE-TYPE LOCAL ANESTHETICS maximum dose of 500 mg12 (Table4-5).

Lidocaine HCI Comments. Lidocaine HCl was synthesizedin 1943and in


Pertinent Information 1948was the first amide local anesthetic to be marketed. Its
Classification. Amide. entry into clinicalpractice transformed dentistry; it replaced
Chemical Formula. 2-Diethylamino-2',6-acetoxylidide procaine (Novocain) as the drug of choice for pain control.
hydrochloride. Compared with procaine, lidocaine possessesa significantly
more rapid onset of action {3 to 5 minutes vs. 6 to 10
minutes), produces more profound anesthesia,has a longer
duration of action, and has greater potency.
Allergyto amide local anestheticsis virtually nonexistent;
true, documented, and reproducible allergic reactions are
extremelyrare, although possible.":" This is a major clinical
advantage oflidocaine (and all amides) over ester-typelocal
Prepared by. Nils Lofgren, 1943. anesthetics.8
FDA Approved. November 1948. Within only a fewyears of its introduction, lidocaine had
Potency. 2 (compared with procaine) (procaine = 1; replacedprocaine as the most widelyused local anesthetic in
lidocaine remains the standard of comparison [lidocaine both medicine and dentistry-a position it maintains today
= 1] for all local anesthetics). in most countries. It represents the "goldstandard,"the drug
Toxicity. 2 (compared with procaine). against which all new local anesthetics are compared.

TABLE 4-5
Lidocaine Hydrochloride
DURATION
Proprietary % LA Vasoconstrictor Pulpal Soft Tissue MRD
Lidocaine HCl
2 Epinephrine 1: 50,000 60 180-300 7.0 mg/kg
3.6 mg/lb 500 mg absolute maximum
2 Epinephrine 1: 100,000 60 180-300 7.0 mg/kg
3.6 mg/lb 500 mg absolute maximum
MRD, Maximum recommended dose.

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CHAPTER 4 Clinical Action of Specific Agents 59

....• -~.•......•

---~2'­
(l..lDOCAJNEHYDROCHLORIDE
ANO EPINEPHRINEIN.JfCTlai, USP)
~t:SOOQO~
=..

81

C1
Figure 4-2. A, Lidocaine 2%. B, Lidocaine 2% with epinephrine 1: 50,000.C, Lidocaine with epinephrine 1: 100,000.(A, Courtesy Dent­
sply, York, Pa. B and C, Courtesy Eastman Kodak, New York, NY, and Septodont, New Castle, Del.)

Lldocaine HCl is available in North America in two minutes). This vasodilatory effectleads to (1) higher blood
formulations: 2% with epinephrine 1:50,000,and 2% with levelsof lidocaine, with an attendant increase in the risk of
epinephrine 1: 100,000(Fig.4-2). A 2% lidocaine with epi­ adversereactions, along with (2) increased perfusion in the
nephrine 1:300,000formulation is availablein some coun­ area of drug deposition. Few clinical indications are known
tries (although not in North Americaas of August2011).2% for the use of 2% lidocaine without a vasoconstrictor in the
lidocaine without epinephrine (2% "plain") is no longer typical dental practice. As of August 2011, 2% lidocaine
availablein dental cartridges in North America. without epinephrine (2% "plain") was no longer availablein
1\ilroPercent Lidocaine HCI Without a Vasoconstrictor dental cartridges in North America.
(Lidocaine Plain). Its vasodilating properties severelylimit 1\ilro Percent Lidocaine With Epinephrine f:50,000.
the duration and the depth of pulpal anesthesia (5 to 10 (Table4-6)

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60 PARTI The Drugs

TABLE 4-6 TABLE 4-7


Lidocaine 2% With Epinephrine 1 : 50,000*t Lidocaine 2% With Epinephrine 1 : 100,000*tt:
CONCENTRATION: 2% CARTRIDGE CONTAINS: 36 mg CONCENTRATION: 2% CARTRIDGE CONTAINS: 36 mg
MRD: 7.0 mg/kg MRD: 3.2 mg/lb MRD: 7.0 mg/kg MRD: 3.2 mg/lb
Weight. Weight. Weight, Weight,
kg mg Cartridges:!: lb mg Cartridges:!: kg mg Cartridges* lb mg Cartridges*
10 70 2.0 20 72 2.0 10 70 2.0 20 72 2.0
20 140 4.0 40 144 4.0 20 140 4.0 40 144 4.0
30 210 6.0§ 60 216 6.0§ 30 210 6.0 60 216 6.0
40 280 6.0§ 80 288 6.0§ 40 280 7.5 80 288 8.0
50 350 6.0§ 100 360 6.0§ 50 350 9.5 100 360 10.0
60 420 6.0§ 120 432 6.0§ 60 420 11.0§ 120 432 11.0§
70 490 6.0§ 140 500 6.0§ 70 490 11.0§ 140 500 11.0§
80 500 6.0§ 160 500 6.0§ 80 500 11.0§ 160 500 11.0§
90 500 6.0§ 180 500 6.0§ 90 500 11.0§ 180 500 11.0§
100 500 6.0§ 200 500 6.0§ 100 500 11.0§ 200 500 11.0§
MRD, Maximum recommended dose. MRD, Maximum recommended dose.
*Aswith all local anesthetics,the dose varies, depending on the area to be *Aswith all local anesthetics,the dose varies, depending on the area to be
anesthetized,the vascularity of the tissues, individual tolerance, and the anesthetized,the vascularity of the tissues,individual tolerance, and the
technique of anesthesia.The lowest dose needed to provide effective technique of anesthesia.The lowest dose needed to provide effective
anesthesia should be administered. anesthesia should be administered.
+Dosesindicated are the maximum suggestedfor normal healthy +Dosesindicated are the maximum suggestedfor normal healthy
individuals (ASA1); they should be decreasedfor debilitated or elderly individuals (ASA1); they should be decreasedfor debilitated or elderly
patients. patients.
:j:Roundeddown to the nearest half-cartridge. :j:Roundedto the nearest half-cartridge.
§200 µg of epinephrine is the dose-limiting factor (1:50,000 contains §200 µg of epinephrine is the dose-limiting factor (1: 100,000contains
36 µg/cartridge). 18 µg/cartridge).

Inclusion of epinephrine produces a decrease in blood Administration of 2% lidocaine with epinephrine


flow (perfusion), leading to decreased bleeding in the area 1: 100,000decreases blood flow into the area of injection.
of drug administration caused by the a-stimulating actions Duration of action is increased: approximately 60 minutes
of epinephrine. Because of this decrease in perfusion, the of pulpal anesthesia and 3 to 5 hours of soft tissue anes­
local anesthetic is absorbed into the cardiovascular system thesia. In addition to the lower blood levelof lidocaine,less
more slowly(therebyremaining at the site of administration bleeding occurs in the area of drug administration. The
longer, it is hoped near the nerve), leading to an increase epinephrine dilution is 10 µg/mL, or 18 µg per cartridge.
in both depth and duration of anesthesia: approximately Epinephrine-sensitive patients (see earlier discussion for
60 minutes of pulpal anesthesia and 3 to 5 hours of lidocaine with 1:50,000 epineprhine) should be limited to
soft tissue anesthesia. The resultant blood level of local two cartridges of 1: 100,000epinephrine per appointment.
anesthetic is also decreased. The 1:50,000 epinephrine The duration and depth of pulpal anesthesia attained
concentration is equal to 20 µg/mL, or 36 µg per cartridge. with both lidocaine-epinephrine solutions (1 :50,000 and
For patients weighingmore than 45 kg (100 lb), the limiting 1: 100,000)are equivalent.Each may provide approximately
factor in determining the MRD of this local anesthetic 60 minutes of pulpal anesthesia in ideal circumstances and
combination is the maximum epinephrine dose of 200 µg soft tissue anesthesia of 3 to 5 hours' duration. Indeed, 2%
for the healthy patient. The MRD for epinephrine-sensitive lidocainewith 1:200,000or 1:300,000epinephrine provides
individuals (e.g., certain cardiovascularly compromised the same duration of pulpal and soft tissue anesthesia,
patients [American Society of Anesthesiologists Physical although not the same levelof hemostasis.19
Status classificationsystem {ASA}3] and clinicallyhyper­ In terms of duration and depth of anesthesia for most
thyroid patients [ASA3]) is 40 µg per appointment. This is procedures in a typical dental patient, 2% lidocaine with
equivalent to about one cartridge of 1:50,000 epinephrine 1: 100,000 epinephrine is preferred to 2% lidocaine with
(see Chapter 20). 1:50,000 epinephrine. Both formulations provide equal
The only recommended use of 2% lidocaine with a duration and depth, but the 1: 100,000 solution contains
1:50,000 epinephrine concentration is for hemostasis (a only half as much epinephrine as the 1:50,000 solution.
situation wherein only small volumes are infiltrated directly Although the dose of epinephrine in the 1:50,000 solution
into the surgical site). is not dangerous to most patients, ASA-3and -4 risks with
Two Percent Lidocaine With Epinephrine 1: 100,000. histories of cardiovasculardisorders might prove overlysen­
(Table4-7) sitiveto these concentrations.Also,an elderlypatient is likely

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CHAPTER 4 Clinical Action of Specific Agents 61

to be more hyper-responsive to vasoconstrictors. In these vasopressor levonordefrin, and in 1961 as a 3% solution


individuals, the more dilute formulation (1 : 100,000 or without a vasoconstrictor.
1:200,000) should be used. FDA Approved. April 1960.
For hemostasis in procedures in which bleeding is defi­ Potency. 2 (procaine= l; lidocaine = 2).
nitely or potentially a problem, 2% lidocaine with 1:50,000 Toxicity. 1.5 to 2 (procaine= l; lidocaine = 2).
epinephrine is recommended because it decreases bleed­ Metabolism. In the liver, by microsomal fixed-function
ing (during periodontal surgery) by 50% compared with oxidases. Hydroxylation and N-demethylation play impor­
a 1: 100,000 epinephrine dilution." Vasoconstrictors act tant roles in the metabolism of mepivacaine.
directly at the site of administration to decrease tissue perfu­ Excretion. Via the kidneys; approximately 1% to 16% of
sion, and the 1:50,000 solution provides excellent hemo­ anesthetic dose is excreted unchanged.
static action. The 1: 100,000 dilution also may be used for Vasodilating Properties. Mepivacaine produces only
hemostasis, but it is not as effective. Rebound vasodilation slight vasodilation. The duration of pulpal anesthesia with
occurs with both 1:50,000 and 1 : 100,000 epinephrine mepivacaine without a vasoconstrictor is 20 to 40 minutes
concentrations as the tissue concentration of epinephrine (lidocaine without a vasoconstrictor is but 5 to 10 minutes;
decreases. Minimum volumes of solution should be admin­ procaine without a vasoconstrictor may produce effects up
istered to provide excellent hemostasis. to 2 minutes).
Signs and symptoms oflidocaine toxicity (overdose) may pKa. 7.6.
be the same (central nervous system [CNS] stimulation fol­ pH of Plain Solution. 5.5 to 6.0.
lowed by CNS depression) as those described in Chapter 2. pH of Vasoconstrictor-Containing Solution. 4.0.
However, the stimulatory phase may be brief or may not Onset of Action. Rapid (3 to 5 minutes).
develop at all.21Although muscle tremor and seizures com­ Effective Dental Concentration. 3% without a vasocon­
monly occur with overly high lidocaine blood levels, the first strictor; 2% with a vasoconstrictor.
signs and symptoms of lidocaine overdose may include Anesthetic Half-Life. 1.9 hours.
drowsiness, leading to loss of consciousness and respiratory Topical Anesthetic Action. Not in clinically acceptable
arrest. concentrations.
Pregnancy Classification. C.
Safety During Lactation. S?
Mepivacaine HCI
Pertinent Information Maximum Recommended Dose. MRD is 6.6 mg/kg or
Classification. Amide. 3.0 mg/kg of body weight, not to exceed 400 mg22 (Table
Chemical Formula. I-methyl 2',6'-pipecoloxylidide 4-8).
hydrochloride.
Comments. The milder vasodilating property of mepiva­
caine leads to a longer duration of pulpal anesthesia than is
observed with most other local anesthetics when adminis­
tered without a vasoconstrictor. Mepivacaine 3% plain pro­
vides 20 to 40 minutes of pulpal anesthesia (20 minutes via
infiltration; 40 minutes via nerve block) and approximately
2 to 3 hours of soft tissue anesthesia.
Three Percent Mepivacaine Without a Vasoconstric­
tor. (Fig. 4-3 and Table 4-9)
Prepared by. A.F. Ekenstam, 1957; introduced into den­ This is recommended for patients in whom a vasocon­
tistry in 1960 as a 2% solution containing the synthetic strictor is not indicated and for dental procedures requiring

TABLE 4-8
Mepivacaine Hydrochloride
DURATION
Proprietary % LA Vasoconstrictor PuIpal Soft Tissue MRD
MepivacaineHCI 3 None 20-infiltration 120-180 6.6 mg/kg
40-nerve block 3.0 mg/lb
400 mg absolute maximum
MepivacaineHCI 2 Levonordefrin 60 180-300 6.6 mg/kg
3.0 mg/lb
400 mg absolute maximum
MRD, Maximum recommended dose.

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62 PARTI The Drugs

-
c:
~

=
~ c:a...!l0 ,1,•..

Figure 4-3. A through C, Mepivacaine 3%. D, Mepivacaine 2% with levonordefrin 1 :20,000. (A, Courtesy Dentsply, York, Pa. B, Courtesy
Eastman Kodak, New York, NY. D, Courtesy Septodont, New Castle, Del.)

TABLE 4-9 neither lengthy nor profound pulpal anesthesia. Mepiva­


Mepivacaine 3% Without Vasoconstrictor*t caine plain is the most used local anesthetic in pediatric
CONCENTRATION: 3% CARTRIDGE CONTAINS: 54 mg patients when the treating doctor is not a pediatric dentist
MRD: 6.6 mg/kg MRD: 3.0 mg/lb (e.g.,is a generalpractitioner) and often is quite appropriate
Weight. Weight. in the management of geriatric patients.
kg mg cartridges:!: lb mg cartridges:!: 1\vo Percent Mepivacaine With a Vasoconstrictor,
Levonordefrin 1:20,000. (Table 4-10)
10 66 1.0 20 60 1.0
20 132 2.5 40 120 2.0 This solution provides depth and duration of pulpal
30 198 3.5 60 180 3.0 (hard tissue) and total (soft tissue) anesthesia similar to
40 264 4.5 80 240 4.5 those observedwith lidocaine-epinephrine solutions. Pulpal
50 330 6.0 100 300 5.5 anesthesia of approximately 60 minutes' duration and soft
60 396 7.0 120 360 6.5 tissue anesthesia of 3 to 5 hours are to be expected.
70 400 7.5 140 400 7.5 Mepivacaineis availablein combination with levonordefrin
80 400 7.5 160 400 7.5 (1:20,000). Where hemostasis is desired , epinephrine is
90 400 7.5 180 400 7.5 preferred to levonordefrin.
100 400 7.5 200 400 7.5 The incidence of true, documented, and reproducible
MRD, Maximum recommended dose. allergyto mepivacaine,an amide local anesthetic,is virtually
*As with all local anesthetics,the dose varies, depending on the area to be nonexistent.
anesthetized,the vascularity of the tissues, individual tolerance, and the Signs and symptoms of mepivacaine overdose usually
technique of anesthesia.The lowest dose needed to provide effective
anesthesia should be administered.
follow the more typical pattern of CNS stimulation fol­
tDoses indicated are the maximum suggestedfor normal healthy lowed by depression.Although possible,absenceof stimula­
individuals (ASA1); they should be decreasedfor debilitated or elderly tion with immediate CNS depression (e.g., drowsiness and
patients. unconsciousness,as is seen more commonly with lidocaine)
:j:Roundeddown to the nearest half-cartridge. is rare with mepivacaine.

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CHAPTER 4 ClinicalAction of SpecificAgents 63

Orthotoluidine can induce the formation of methemoglo­


TABLE 4-10
bin, producing methemoglobinemia if large doses are
Mepivacaine 2% With Vasoconstrictor*t
administered. Minor degrees of methemoglobinemia have
CONCENTRATION: 2% CARTRIDGE CONTAINS: 36 mg been observed following both benzocaine and lidocaine
MRD: 6.6 mg/kg MRD: 3.0 mg/lb administration,24.25 but prilocaine consistently reduces the
Weight. Weight. blood's oxygen-carrying capacity, at times sufficiently to
kg mg Cartridges:!: lb mg Cartridges:!: cause observable cyanosis.26•27 Limiting the total prilocaine
10 66 1.5 20 60 1.5 doseto 600 mg (FDArecommendation) avoidssymptomatic
20 132 3.5 40 120 3.0 cyanosis.Methemoglobinblood levelslessthan 20% usually
30 198 5.5 60 180 5.0 do not produce clinical signs or symptoms (which include
40 264 7.0 80 240 6.5 grayish or slate blue cyanosis of the lips, mucous mem­
50 330 9.0 100 300 8.0 branes, and nail beds and [infrequently]respiratory and cir­
60 396 11.0 120 360 10.0 culatory distress). Methemoglobinemia may be reversed
70 400 11.0 140 400 11.0
within 15minutes with administration of 1to2 mg/kg body
80 400 11.0 160 400 11.0
weight of 1% methylene blue solution intravenously over a
90 400 11.0 180 400 11.0
100 400 11.0 200 400 11.0 5-minute period.25 The mechanism of methemoglobin pro­
duction is discussed in Chapter 10. Prilocaine undergoes
MRD, Maximum recommended dose.
biotransformation more rapidly and completely than lido­
*Aswith all local anesthetics,the dose varies, depending on the area to be
anesthetized,the vascularity of the tissues, individual tolerance, and the
caine;this takes place not only in the liverbut also to a lesser
technique of anesthesia.The lowest dose needed to provide effective degreein the kidneysand lungs.27 Plasmalevelsof prilocaine
anesthesia should be administered. decrease more rapidly than those of lidocaine.28 Prilocaine
+Dosesindicated are the maximum suggestedfor normal healthy thus is considered to be less toxic systemicallythan compa­
individuals (ASA1); they should be decreasedfor debilitated or elderly rably potent local anesthetic amides.29 Signsof CNStoxicity
patients.
:j:Roundeddown to the nearest half-cartridge.
after prilocaine administration in humans are briefer and
less severe than after the same intravenous (N) dose of
lidocaine.30
Excretion. Prilocaine and its metabolites are excreted
primarily via the kidneys. Renal clearance of prilocaine is
Prilocaine HCI faster than for other amides, resulting in its faster removal
Pertinent Information from the circulation.31
Classification. Amide. Vasodilating Properties. Prilocaine is a vasodilator. It
Other Chemical Name. Propitocaine. produces greater vasodilation than is produced by mepiva­
Chemical Formula. 2-Propylamino-o-propionotoluidide caine but less than lidocaine and significantly less than
hydrochloride. procaine.
pK•. 7.9.
pH of Plain Solution. 6.0 to 6.5.
pH of Vasoconstrictor-Containing Solution. 4.0.
Onset of Action. Slightlyslower than that of lidocaine
(3 to 5 minutes).
Effective Dental Concentration. 4%.
Anesthetic Half-Life. 1.6hours.
Topical Anesthetic Action. Not in clinicallyacceptable
concentrations.
Prepared by. LOfgren and Tegner, 1953; reported in Prilocaine, in its uncharged base form, is an integral
1960. part of EMLAcream (eutecticmixture of the local anesthet­
FDA Approved. November 1965. ics lidocaine and prilocaine), a formulation that permits
Potency. 2 (procaine= 1;lidocaine = 2). anesthetics to penetrate the imposing anatomic barrier of
Toxicity. 1 (procaine= 1; lidocaine = 2); 40% less toxic intact skin. EMLAcream is used to provide topical anesthe­
than lidocaine. sia of skin before venipuncture and other painful cosmetic
Metabolism. The metabolism of prilocaine differs sig­ procedures.33'34
nificantly from that of lidocaine and mepivacaine. Because Pregnancy Classification. B.
it is a secondary amine, prilocaine is hydrolyzed straight­ Safety During Lactation. Unknown.
forwardly by hepatic amidases into orthotoluidine and
N-propylalanine. Carbon dioxide is a major end product of Maximum Recommended Dose. The MRD for prilocaine
prilocaine biotransformation. The efficiencyof the body's is 8.0 mg/kg or 3.6 mg/lb of body weight for the adult
degradation of prilocaine is demonstrated by the extremely patient, to a maximum recommended dose of 600 mg
small fraction of intact prilocaine recoverablein the urine.23 (Table4-11).31

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64 PART I The Drugs

TABLE 4-11
Prilocaine Hydrochloride
DURATION
Proprietary % LA Vasoconstrictor Pulpal Soft Tissue MRD
Prilocaine HCl 4 None 10-15infiltration 90-120 infiltration 8.0 mg/kg
40-60 nerve block 120-240nerve block 3.6 mg/lb
600 mg absolute maximum
Prilocaine HCl 4 Epinephrine 60-90 180-480 8.0 mg/kg
1:200,000 3.6 mg/lb
600 mg absolute maximum
MRD, Maximum recommended dose.

---
•111: •••••
-------
~---~ ~--------~-~----
A~ ,_Ml\llVI

4"::__':ioq.ooo
wilh apiiephrint
(prilocoine and epinephrine
Injection. USP)
40,..Jri

A c

B D
Figure 4-4. A and B, Prilocaine 4%. C and D, Prilocaine 4% with epinephrine 1:200,000.(Courtesy Dentsply,York,Pa.)

Comments. Clinical actions of prilocaine plain (Fig. 4-4) Clinicalactions of prilocaine with 1:200,000epinephrine
vary significantlywith the type of injection technique used are not as dependent on anesthetic technique. Prilocaine
Although true for all anesthetics, the variation between with epinephrine provides lengthy anesthesiawhile offering
supraperiosteal infiltration and nerve block is more pro­ a less concentrated epinephrine dilution: 1:200,000.Pulpal
nounced with prilocaine plain (and mepivacaine plain). anesthesiaof 60 to 90 minutes' duration and soft tissue anes­
Infiltration provides short durations of pulpal {10 to 15 thesia of 3 to 8 hours are common. The cartridge contains
minutes) and soft tissue {l,Vi to 2 hours) anesthesia,whereas 9 µg of epinephrine; therefore epinephrine-sensitive indi­
regional nerve block (e.g.,inferior alveolarnerve block) pro­ viduals, such as the A5A 3 cardiovascular disease patient,
vides pulpal anesthesiafor up to 60 minutes (commonly 40 may receiveup to four cartridges (36 µg) of prilocaine with
to 60 minutes) and soft tissue anesthesia for 2 to 4 hours.32 epinephrine.
Thus prilocaine plain frequentlyis ableto provide anesthesia In epinephrine-sensitive patients requiring prolonged
that is equal in duration to that attained with lidocaine or pulpal anesthesia {~60 minutes), prilocaine plain or with
mepivacainewith a vasoconstrictor. 1:200,000epinephrine is stronglyrecommended.It israpidly

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CHAPTER 4 Clinical Action of Specific Agents 65

D
TABLE 4-12 COOCH3
Prilocaine 4% With and Without Vasoconstrictor*t • HCI
CONCENTRATION: 4% CARTRIDGE CONTAINS: 72 mg
MRD: 8.0 mg/kg MRD: 3.6 mg/lb NHCOCHNHCH2CH2CH3
H3C I
Weight. Weight.
CH3
kg mg Cartridges:!: lb mg Cartridges:!:
10 80 1.0 20 72 1.0 Prepared by. H. Rusching et al, 1969.
20 160 2.0 40 144 2.0 FDA Approved. April 2000 (United States).
30 240 3.0 60 218 3.0 Introduced. 1976 in Germany and Switzerland, 1983 in
40 320 4.5 80 290 4.0 Canada, 2000 in the United States.
50 400 5.5 100 362 5.0 Potency. 1.5 times that of lidocaine; 1.9 times that of
60 480 6.5 120 434 6.0 procaine.
70 560 7.5 140 506 7.0
Toxicity. Similar to lidocaine and procaine.
80 600 8.0 160 578 8.0
Metabolism. Articaine is the only amide-type local anes­
90 600 8.0 180 600 8.0
100 600 8.0 200 600 8.0 thetic that contains a thiophene group. Because articaine
HCl is the only widely used amide-type local anesthetic that
MRD, Maximum recommended dose.
contains an ester group, biotransformation of articaine HCl
*Aswith all local anesthetics,the dose varies, depending on the area to be
anesthetized,the vascularity of the tissues, individual tolerance, and the
occurs in both plasma (hydrolysis by plasma esterase) and
technique of anesthesia.The lowest dose needed to provide effective liver (hepatic microsomal enzymes). Degradation of artic­
anesthesia should be administered. aine HCl is initiated by hydrolysis of the carboxylic acid ester
+Dosesindicated are the maximum suggestedfor normal healthy groups to obtain free carboxylic acid.37 Its primary metabo­
individuals (ASA1); they should be decreasedfor debilitated or elderly lite, articainic acid, is pharmacologically inactive, undergo­
patients.
:j:Roundedto the nearest half-cartridge. ing additional biotransformation to form articainic acid
glucuronide.37 Additional metabolites have been detected in
animal studies. 38 From this point, the reaction can follow
several pathways: cleavage of carboxylic acid, formation of
an acid amino group by internal cyclization, and oxidation.
biotransformed and, for this reason, is considered to be a safe Excretion. Via the kidneys; approximately 5% to 10%
local anesthetic (e.g., lower toxicity).28 unchanged, approximately 90% metabolites (M1 at 87%, M2
Prilocaine is relatively contraindicated in patients with at 2%).
idiopathic or congenital methemoglobinemia, hemoglo­ Vasodilating Properties. Articaine has a vasodilating
binopathies (sickle cell anemia), anemia, or cardiac or effect equal to that of lidocaine. Procaine is slightly more
respiratory failure evidenced by hypoxia, because methemo­ vasoactive.
globin levels are increased, decreasing oxygen-carrying pK•. 7.8.
capacity. Prilocaine administration is also relatively contra­ pH of Plain Solution. Not available in North America
indicated in patients receiving acetaminophen or phenace­ (4% articaine HCl "plain" is available in Germany).
tin, both of which produce elevations in methemoglobin pH of Vasoconstrictor-Containing Solution. 3.5 to 4.0.
levels (Table 4-12). Onset of Action. Articaine 1 :200,000, infiltration 1 to
It has been claimed that prilocaine HCl 4% solution 2 minutes, mandibular block 2 to 3 minutes; articaine
(with or without vasopressor) is associated with a higher risk 1: 100,000, infiltration 1 to 2 minutes, mandibular block 2
of paresthesia, primarily of the lingual nerve, than other to 2,Vi minutes.
anesthetic formulations following inferior alveolar nerve Effective Dental Concentration. 4% with 1 : 100,000 or
block.34•35 Although the "evidence" remains anecdotal, it 1:200,000 epinephrine. Articaine HCl is available with epi­
appears that this drug, as formulated in North America [as nephrine 1 :400,000 in Germany.
a 4% solution], might be more neurotoxic than other com­ Anesthetic Half-Life. 0.5 hours [27 minutes].39
monly used local anesthetic formulations.36 This question Topical Anesthetic Action. Not in clinically acceptable
will be discussed in greater detail in Chapter 17. concentrations.
Pregnancy Classification. C.
Safety During Lactation. Unknown (use with caution in
Articaine HCI females who are breast-feeding because it is not known
Pertinent Information whether articaine is excreted in milk).
Classification. Hybrid molecule. Classified as an amide;
however, it possesses both amide and ester characteristics. Maximum Recommended Dose. The FDA maximum rec­
Chemical Formula. 3-N-Propylamino-proprionylamino- ommended dose is 7.0 mg/kg or 3.2 mg/lb of body weight
2-carbomethoxy-4-methylthiophene hydrochloride. for the adult patient (Tables 4-13 and 4-14).22•40

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66 PARTI The Drugs

TABLE 4-13
Articaine Hydrochloride
DURATION
Proprietary % LA Vasoconstrictor PuIpal Soft Tissue MRD
Articaine HCl 4 Epinephrine 1: 100,000 60-75 180-360 7.0mg/kg
3.2 mg/lb
No absolute maximum
Articaine HCl 4 Epinephrine 45-60 120-300 7.0mg/kg
1:200,000 3.2 mg/lb
No absolute maximum
MRD, Maximum recommended dose.

formulation with 1: 100:000 epinephrine provides between


TABLE 4-14 60 and 75 minutes of pulpal anesthesia;the 1:200,000for­
Articaine 4% With Epinephrine 1 :100,000 mulation, approximately45 to 60 minutes.t="
or 1:200,000*t
Since its introduction into the U.S. dental market in
CONCENTRATION: 4% CARTRIDGE CONTAINS: 72 mg June2000,articainehas steadilybecomeincreasinglypopular.
MRD: 7.0 mg/kg MRD: 3.6 mg/lb As of May 2011 articaine was the second most used dental
Weight, Weight, local anesthetic in the United States (=40% market share)."
kg mg Cartridges:!: lb mg Cartridges:!: Articaine, as the newest local anesthetic drug marketed, has
10 70 1.0 20 72 1.0 been the subject of intense discussion and of many (anec­
20 140 2.0 40 144 2.0 dotal) claims made by dentists, some good (faster onset,
30 210 3.0 60 216 3.0 increased success rates; "don't miss as often"), some bad
40 280 4.0 80 288 4.0 (increased risk of paresthesia). It has been claimed that
50 350 5.0 100 360 5.0 articaine is able to diffuse through soft and hard tissues
60 420 6.0 120 432 6.0 more reliablythan other local anesthetics.F'" Clinically,it is
70 490 7.0 140 504 7.0
claimed that following maxillary buccal infiltration, artic­
80 560 8.0 160 576 8.0
aine on occasion may provide palatal soft tissue anesthesia,
90 630 9.0 180 648 9.0
100 700 10.0 200 720 10.0
obviating the need for palatal injection, which, in many
hands, is traumatic.48
MRD, Maximum recommended dose.
Some initial claims about articaine have been shown to
*Aswith all local anesthetics,the dose varies, depending on the area to be
anesthetized,the vascularity of the tissues, individual tolerance, and the
be true, specifically,the significant success of articaine
technique of anesthesia.The lowest dose needed to provide effective administered by buccal infiltration in the mandible of adult
anesthesia should be administered. patients. 49-55 This is discussedmore fully in Chapter 20.
+Dosesindicated are the maximum suggestedfor normal healthy The successof articaine in the United States mirrors its
individuals (ASA1); they should be decreasedfor debilitated or elderly success elsewhere. In Germany, the first country to have
patients.
:j:Roundedto the nearest half-cartridge.
articaine (1976), by 1989it was used by 71.7% of German
dentists,56 and by2010 it commanded 95% of the dental local
anesthetic market.57 Articaine has become the leading local
anesthetic in Canada, which acquired it in 1983; in the
Comments. Originally known as carticaine, the generic United States,where articaine has been availablesince June
nomenclature of this local anesthetic was changed in 1984 of 2000,it presently (May2011) commands 40% of the local
to articaine. Literature appearing before 1984 should be anesthetic market.46
reviewedunder the original name. Reports of paresthesia followinglocal anesthetic admin­
Articaine is the only anesthetic of the amide type to istration became more frequent after the introduction of
possessa thiophene ring as its lipophilic moiety.It has many articaine into the United States.An overwhelmingmajority
of the physicochemicalproperties of other local anesthetics, of reported cases occurred followinginferior alveolarnerve
with the exception of the aromatic moiety and the degree of block and primarily involvedthe lingual nerve.The question
protein binding. of paresthesiarelated to local anesthetic drug administration
Articaine has been availablein Europe since 1976and in is addressed in depth in Chapter 17.
Canada since 1984in two formulations: 4% with 1: 100,000 In previous editions of this textbook, methemoglobin­
epinephrine and 4% with 1:200,000epinephrine (Fig.4-5). emia was listed as a potential side effectof administration of
In 2000 the FDAapproved articaine HCl with epinephrine largedosesof articaine.58 Suchreactionshad been noted after
1: 100,000 for marketing in the United States.41-43 The the N administration of articaine for regional anesthetic

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CHAPTER 4 ClinicalAction of SpecificAgents 67

.
Septocetne 111 .-\niaim• lndrod1loritk ./".. 11i1/r

-
Epi11•·i1l1rirn· 1:100.(}()(}lni•~lirm

c::
.g
.s
~ 50~.--Ql-'.l.7rnl.
-
(/)

Figure 4-5. Articaine 4% with epinephrine 1: 100,000 and 1 :200,000. (Courtesy Septodont, New Castle, Dd.)

purposes; however,no cases have ever been reported when


articaine was administered in the usual manner and volume
for dental procedures.
Articaine HCl with epinephrine is contraindicated in
persons with known sensitivity to amide-type local anes­
thetics (few to none) and in persons with sulfite sensitivity
(such as some asthmatic patients with allergic-typeasthma,
as epinephrine-containing LA formulations contain the
antioxidant Na metabisulfite). Articaine HCl should be
used with caution in persons with hepatic disease and
significant impairment in cardiovascular function because
amide-type local anesthetics undergo biotransformation in
the liver and possess myocardial depressant properties.
Articaine is listed by the U.S.FDAas a Class C drug during
pregnancy. Use with caution in females who are breast­
feedingbecauseit is not known whether articaine is excreted
in milk.59 Administration to children younger than 4 years is
not recommended because insufficient data are availableto
Figure 4-6. Articaine box showing "1.7 ml each."
support such usage.
Cartridges of articaine marketed in the United States are
listed as containing "1.7 mL" (Fig.4-6), in contrast to other
local anesthetic cartridges, which are labeled as "1.8 mL:'
Somemight interpret this to mean that the cartridge consists
of 68 mg. This is incorrect. Articaine HCl cartridges are
identical in all ways to other dental cartridges. However,as
discussedearlier in this chapter,a changewas made to label­
ing, not to content. Prepared by. A.F.Ekenstam, 1957.
FDA Approved. October 1972.
Potency. Four times that of lidocaine, mepivacaine,and
Bupivacaine HCI prilocaine.
Pertinent Information Toxicity. Less than four times that of lidocaine and
Classification. Amide. mepivacaine.
Chemical Formula. 1-Butyl-2',6'-pipecoloxylididehydro­ Metabolism. Metabolizedin the liver by amidases.
chloride; structurally related to mepivacaine except for a Excretion. Via the kidney; 16% unchanged bupivacaine
butyl group replacing a methyl group. has been recoveredfrom human urine.

www.ShayanNemoodar.com
68 PARTI The Drugs

Vasodilating Properties. Relatively significant: greater administration of any suitable (e.g., intermediate-duration)
than those of lidocaine, prilocaine, and mepivacaine, yet local anesthetic to manage periprocedural pain. A long­
considerably less than those of procaine. duration local anesthetic (bupivacaine) is administered
pK•. 8.1. immediately before patient discharge (if deemed necessary),
pH of Plain Solution. 4.5 to 6.0. with the patient continuing to take the oral dose of NSAID
pH of Vasoconstrictor-Containing Solution. 3.0 to 4.5. every "x" hours as indicated (not "prn pain") for "y" number
Onset of Action. Slower onset time than other com- of days. The requirement for opioid agonist analgesics is
monly used local anesthetics (e.g., 6 to 10 minutes). significantly diminished with this protocol. Hargreaves dem­
Effective Dental Concentration. 0.5%. onstrated that the preoperative oral dose of NSAID is not
Anesthetic Half-Life. 2.7 hours. necessary as long as the initial oral dose can be ingested
Topical Anesthetic Action. Not in clinically acceptable within 1 hour of the start of the surgical procedure. 65
concentrations. Onset of anesthesia with bupivacaine is commonly
Pregnancy Classification. C. delayed for from 6 to 10 minutes, a fact that is understand­
Safety During Lactation. S? able in view of its pl<,. of 8.1. If this occurs, it may be
advisable, at subsequent appointments, to initiate proce­
Maximum Recommended Dose. The FDA maximum rec­ dural pain control with a more rapid-acting amide (e.g.,
ommended dose ofbupivacaine is 90 mg. There is no recom­ articaine, mepivacaine, lidocaine, prilocaine), which pro­
mended dosage for bupivacaine based on body weight in the vides clinically acceptable pain control within a few moments,
United States (Table 4-15).60 In Canada, the maximum dose allowing the procedure to commence more promptly. Follow
is based on 2.0 mg/kg (0.9 mg/lb). this with an injection of bupivacaine for long-duration
anesthesia.
Comments. Bupivacaine has been available in cartridge Bupivacaine is not recommended in younger patients
form since February 1982 in Canada and July 1983 in the or in those for whom the risk of postoperative soft tissue
United States. Bupivacaine is available as a 0.5% solution injury produced by self-mutilation is increased, such as
with 1: 200,000 epinephrine (Fig. 4-7); there are two primary physically and mentally disabled persons. Bupivacaine is
indications for its utilization in dentistry:
1. Lengthy dental procedures for which pulpal (deep)
anesthesia in excess of 90 minutes is necessary (e.g., full
mouth reconstruction, implant surgery, extensive
periodontal procedures)
2. Management of postoperative pain (e.g., endodontic,
periodontal, postimplant, surgical)
The patient's requirement for postoperative opioid anal­
gesics is considerably lessened when bupivacaine is admin­
istered for pain control.61 For postoperative pain control
after a short surgical procedure (<30 minutes), bupivacaine
may be administered at the start of the procedure; however,
for postoperative pain control after lengthy surgical proce­
dures, it might be reasonable to administer bupivacaine at
the conclusion of the procedure, shortly before the patient's
discharge from the office.
A regimen for management of postsurgical pain has been
developed that is clinically quite effective. 62-64 It suggests
the pretreatment administration of one oral dose of a Figure 4- 7. Bupivacaine 0.5% with epinephrine 1:200,000.
nonsteroidal anti-inflammatory drug (NSAID), followed by (Courtesy Eastman Kodak,NewYork,NY.)

TABLE 4-15
Bupivacaine Hydrochloride
DURATION
Proprietary % LA Vasoconstridor Pu Ipal Soft Tissue MRD
BupivacaineHCl 0.5 Epinephrine 1:200,000 90-180 240-540 United States:no mg/kg or mg/lb listed
(reports up to 720) Canada: 2.0 mg/kg, 0.9 mg/lb,
90 mg absolute maximum
MRD, Maximum recommended dose.

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CHAPTER 4 ClinicalAction of SpecificAgents 69

rarely indicated in children because pediatric dental proce­


dures are usually of short duration.
TABLE 4-16
Effective Concentrations for Injection and Topical
Etidocaine HCI Application of Local Anesthetics
Pertinent Information EFFECTIVECONCENTRATION
Classification. Amide. Agent Injection. % Topical.% Useful as Topical
Chemical Formula. 2-(N-Ethylpropylamino)butyro-2,6- Lidocaine 2 2-5 Yes
xylidide hydrochloride; structurally similar to lidocaine. Mepivacaine 2-3 12-15 No
Procaine 2-4 10-20 No
Tetracaine 0.25-1 0.2-1 Yes

application. The base forms of benzocaine and lidocaine are


slowlyabsorbed into the cardiovascularsystemand therefore
are less likely to produce an overdose reaction following
Prepared by. Takman, 1971. typical dental application.
FDA Approved. August 1976. Some topical anesthetics are marketed in pressurized
Dental cartridges of etidocaine HCl with epinephrine spray containers. Although they are no more effectivethan
1:200,000werewithdrawn from the North Americanmarket other forms, it is difficultto control the amount of anesthetic
in 2002. For a detailed description of etidocaine HCl, the expelled and to confine it to the desired site of application.
reader is referred to the 5th edition of this textbook.66 Spraydevicesthat do not delivermeasured doses should not
be used intraorally.
ANESTHETICS FOR TOPICAL APPLICATION Benzocaine
Use of topically applied local anesthetics is an important Benzocaine (ethyl p-aminobenzoate) is an ester local
component of the atraumatic administration of intraoral anesthetic:
local anesthesia(seeChapter 11).Conventionaltopical anes­ 1. Poor solubility in water
thetics are unable to penetrate intact skin but do diffuse
through abraded skin (e.g., sunburn) and any mucous
membranes.
The concentration of a local anesthetic applied topically
is typically greater than that of the same local anesthetic
administered by injection. The higher concentration facili­ 2. Poor absorption into the cardiovascularsystem
tates diffusion of the drug through the mucous membrane. 3. Systemictoxic (overdose)reactions virtually unknown
Higher concentration also increasesthe risk of toxicity,both 4. Remains at the site of application longer, providing a
locally to tissues and systemicallyif the drug is efficiently prolonged duration of action
absorbed.67 Becausetopical anesthetic formulations do not 5. Not suitable for injection
contain vasoconstrictorsand localanestheticshavevasodila­ 6. Localizedallergicreactions may occur after prolonged
tory properties, vascular absorption of some topical formu­ or repeated use. Although allergicreaction to ester
lations is rapid, and blood levels may quickly reach those anesthetics is rare, ester local anesthetics are more
achievedby direct N administration.67 allergenicthan amide local anesthetics,"
Manylocal anestheticsused effectivelyvia injection prove 7. Inhibits the antibacterial action of sulfonamides"
ineffectivewhen applied topically (e.g.,articaine HCl, mepi­ 8. Availability(Fig.4-8): Benzocaineis availablein the
vacaine HCl, prilocaine HCl, procaine HCl) because the followingformulations in numerous dosages:aerosol,
concentrations necessary to produce anesthesia via topical gel, gel patch, ointment, and solution.
application are high, with significantlyincreased overdose
and local tissue toxicity potential (Table4-16). Benzocaine. Butamben. and Tetracaine HCI
As a general rule, topical anesthetics are effectiveonly on Aerosol,gel,ointment, and solution:benzocaine 140mg/mL;
surfacetissues (2 to 3 mm). Tissuesdeep to the area of appli­ butamben 20 mg/mL; tetracaine HCl, 20 mg/mL.
cation are poorly anesthetized, if at all. However, surface
anesthesia does allow for atraumatic needle penetration of Cocaine Hydrochloride
the mucous membrane.P'" Cocaine hydrochloride (benzoylmethylecgoninehydrochlo­
The topical anesthetics benzocaine and lidocaine base ride) occurs naturally as a white crystalline solid that is
(not the HCl form used by injection) are insoluble in water. highly soluble in water:
However,they are soluble in alcohol,propylene glycol,poly­ 1. Used exclusivelyvia topical application. Injection of
ethylene glycol, and other vehicles suitable for surface cocaine is contraindicated because of the ready

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70 PART I The Drugs

10. Clinical manifestations of mild overdoseinclude


euphoria, excitement,restlessness,tremor,
hypertension, tachycardia,and tachypnea.
11. Clinical manifestations of acute cocaine overdose
include excitement,restlessness,confusion, tremor,
hypertension, tachycardia,tachypnea, nausea and
vomiting, abdominal pain, exophthalmos, and
mydriasis;these are followedby depression (CNS,
cardiovascular,respiratory) and death from respiratory
arrest.
12. It is availablein concentrations ranging from 2% to
10%.
13. It is recommended that the concentration of cocaine
not exceed4% for topical application to oral mucous
membranes.
14. Solutions of cocaine are unstable and deteriorate on
standing.
15. Becauseof the extreme abuse potential of cocaine,its
use as a topical anesthetic in dentistry is not
recommended.
16. Topicallyapplied cocaine is used occasionallybefore
nasal-endotracheal intubation is performed in the
operating theater to minimize bleeding from this
highly vascular region and pain as the endotracheal
tube is passed.
Figure 4-8. A and B, Topical anesthetics containing benzocaine. Dyclonine Hydrochloride
(A, Courtesy Beautlich Pharmaceuticals, Waukegan, Ill. B, Courtesy
Septodont, New Castle, Del.) Dyclonine hydrochloride (4'-butoxy-3-piperidinopropio­
phenone hydrochloride) is a ketone derivative without an
ester or amide linkage that may be used in patients who
are allergic to the common anesthetics. Dyclonine offers
availabilityof more effectiveand much less toxic local advantages over other topical anesthetic agents. Extensive
anesthetics.Cocaine is an ester local anesthetic. experience with the topical preparation has shown it to
2. Onset of topical anesthetic action is quite rapid, be effectiveand safe.72 Dyclonine is marketed in 0.5% and
usually occurring within 1 minute. 1% solutions:
3. Duration of anesthetic action may be as long as 2 1. Cross-sensitizationwith other local anesthetics does not
hours. occur; therefore dyclonine may be used in patients with
4. It is absorbed rapidly but eliminated slowly known sensitivitiesto local anesthetics of other
(elimination half-life= 42 minutes). chemical groups.
5. It undergoes metabolism in the liver and plasma. 2. Slightlysoluble in water
6. Unmetabolized cocaine may be found in the urine. 3. Potency equal to that of cocaine
7. Cocaine is the only local anesthetic consistently 4. Onset of anesthesia slow,requiring up to 10 minutes
demonstrated to produce vasoconstriction,which 5. Duration of anesthesia may be as long as 1 hour.
developsas a result of its ability to potentiate the 6. Systemictoxicity is extremelylow,primarily because of
actions of endogenous epinephrine and the agent's poor water solubility.
norepinephrine.27 Addition of vasoconstrictors to 7. Not indicated for use by injection; irritating to tissues at
cocaine therefore is unnecessary and is potentially the site of application
dangerous, increasingthe likelihood of dysrhythmias, 8. A 0.5% solution is used in dentistry. Maximum
including ventricular fibrillation. recommended dose is 200 mg (40 mL of a 0.5%
8. Classifiedas a ScheduleII drug under the Controlled solution).
SubstancesAct. Repeated use results in psychological 9. Dycloninewas availableas Dyclone in a 0.5% solution:
dependence and tolerance. each 100mL of solution contained 500 mg of dyclonine
9. Overdoseof cocaine is not uncommon followingillicit HCl, 300 mg of chlorobutanol as a preservative,sodium
use, primarily because the drug is readily absorbed chloride for isotonicity,and hydrochloric acid, as
from the nasal mucosa and its dosage is not carefully needed, to adjust pH. The Dyclonebrand was
monitored. withdrawn from the North American market in 2001.

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CHAPTER 4 ClinicalAction of SpecificAgents 71

Bernardi and associatesdemonstrated statisticallysignifi­


EMLA (Eutectic Mixture of Local Anesthetics) cant analgesia in 52 dental patients requiring removal of
EMLAcream (composed of lidocaine 2.5% and prilocaine metal maxillary or mandibular splints used to contain frac­
2.5%) is an emulsion in which the oil phase is a eutectic tures." The authors concluded, "the analgesic effect[s] of
mixture of lidocaine and prilocaine in a ratio of 1: 1 by EMLAcream on oral mucosa allowthe applicationof contact
weight.It was designedas a topical anesthetic ableto provide anesthesia to be broadened to oral surgery and dentistry,
surface anesthesia for intact skin (other topical anesthetics limiting it to those procedures that do not involve deep
do not produce anesthesiaon intact skin, only abraded skin), tissues and only require short-term anesthesia,"?
and as such is used primarily before painful procedures such Munshi and associates reported on the use of EMLA
asvenipuncture and other needle insertions. Originallymar­ cream in 30 pediatric patients undergoing a variety of clini­
keted for use in pediatrics, EMLA has gained popularity cal procedures,including extraction of mobile primary teeth
among needle-phobic adults and persons having other and root stumps and pulpal therapy procedures in the
superficial, but painful, procedures performed (e.g., hair primary teeth, in which EMLAis used as the sole anesthetic
removal). agent.78 Results show that use of EMLAcould eliminate to
EMLAuse has become almost routine during circumci­ some extent use of the needle in procedures performed in
sion," during leg ulcer debridement," and in gynecologic pediatric dentistry.79•80
procedures.75 Becauseintact skin is a barrier to drug diffu­
sion, EMLAmust be applied 1 hour before the procedure. Lidocaine
Satisfactorynumbing of the skin occurs 1hour after applica­ Lidocaine is availablein two forms for topical application:
tion, reaches a maximum at 2 to 3 hours, and lasts for 1 to lidocaine base, which is poorly soluble in water, is used as a
2 hours after removal. 5% concentration, and is indicated for use on ulcerated,
EMLAis supplied in a 5-g or 30-g tube or as an EMLA abraded, or laceratedtissue; and lidocaine hydrochloride,its
anesthetic disc. The EMLAdisc is a white, round, cellulose water-solublepreparation, which is used as a 2% concentra­
disc preloaded with EMLA,packaged in protective laminate tion. The water-soluble form of lidocaine penetrates tissue
foil surrounded by adhesivetape. more efficiently than the base form. However, systemic
EMLAis contraindicated for use in patients with congeni­ absorption is also greater,providing greater risk of toxicity
tal or idiopathic methemoglobinemia, infants younger than than the base form:
12months who arereceivingtreatment with methemoglobin­ 1. Lidocaine is an amide local anesthetic with an
inducing agents, and patients with known sensitivity to exceptionallylow incidence of allergicreactions.
amide-type local anesthetics or any other component of the 2. Maximum recommended dose followingtopical
product.76 application is 200 mg.
BecauseEMLAis effectivein penetrating intact skin, its 3. Availability:Lidocainebase is availableas an aerosol
ability to produce effective topical anesthesia in the oral spray,ointment, patch, and solution in various dosage
cavity seems obvious. Although the drug package insert76 forms (Fig.4-9).
stated originallythat "EMLAis not recommended for use on 4. Availability:LidocaineHCl is availableas an oral topical
mucous membranes:' subsequent clinicaltrials have demon­ solution in 20 mg/mL (viscous) and 40 mg/mL
strated satisfactoryresults.":" (solution).

NDC 0362-5001-50

A
Figure 4-9. Topical anesthetics-Lidocaine. A, Octocaine ointment. B, Dentipatch. (A, Courtesy Septodent, New Castle, DE. B, Courtesy
Noven Pharmaceuticals Inc., Miami, FL, www.noven.com.)

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72 PART I The Drugs

Tetracaine Hydrochloride
TABLE 4-17
Tetracaine hydrochloride (2-dimethylaminoethyl-4- Duration of Pulpal and Soft Tissue Anesthesia for
butylaminobenzoate hydrochloride) is a long-duration ester Available Local Anesthetics
local anesthetic that can be injected or applied topically.
DURATION
1. Highly soluble in water (APPROXIMATE MINUTES)
2. Applied topically,fiveto eight times more potent than
Drug Formulation PuIpal Soft Tissue
cocaine
3. Onset of action after topical application is slow. Mepivacaine3% (infiltration) 5-10 90-120
4. Duration of action is approximately45 minutes after Prilocaine 4% (infiltration) 10-15 60-120
Prilocaine 4% (nerve block) 40-60 120-240
topical application.
Articaine 4% + epinephrine 45-60 180-240
5. Metabolizedin plasma and the liver by plasma
1:200,000
pseudocholinesteraseat a slowerrate than procaine Lidocaine2% + epinephrine 60 180-300
6. When used by injection, availableas a 0.15% 1:50,000
concentration Lidocaine2% + epinephrine 60 180-300
7. 2% concentration is used for topical application. 1:100,000
8. Rapidly absorbed through mucous membranes. Use Mepivacaine2% + 60 180-300
should be limited to small areas to avoid rapid levonordefrin 1:20,000
absorption. Other, more slowlyor poorly absorbed Articaine 4% + epinephrine 60-75 180-300
agents should be used in lieu of tetracaine when larger 1:100,000
areas of topical anesthesia are necessary. Prilocaine 4% + epinephrine 60-90 180-480
9. Maximum recommended dose of 20 mg when used for 1:200,000
topical application. This represents 1 mL of a 2% Bupivacaine0.5% + >90 240-720
epinephrine 1:200,000
solution.
10. Caution is urged because of great potential for
systemictoxicity. (3) the need for hemostasis; and (4) whether any contrain­
11. Availability(Canada): dications exist to administration of the selected local
a. Aerosol:0.7 mg/metered spray anesthetic.P" Table 4-17 lists currently availablelocal anes­
1. Supracaine thetic formulations according to their expected duration of
12. Tetracainein a 3% concentration, with the pulpal and soft tissue anesthesia.Again,it must be noted that
vasoconstrictor oxymetazocine,has been shown to these numbers are approximations, and the actual duration
provide pulpal anesthesia of maxillary teeth when of clinical anesthesia may be somewhat longer or shorter
administered by aerosol spray into a patient's nares.81 than indicated.
Use of intranasal local anesthesia for dental pain A second consideration in the selection of a local anes­
control in discussed in Chapter 20. thetic must be the requirement for pain control after treat­
ment. A long-duration local anesthetic can be administered
when postoperative pain is thought to be a factor. Local
SELECTION OF A LOCAL ANESTHETIC
anesthetics providing a shorter duration of soft tissue anes­
Becauseof the many local anesthetic combinations available thesia can be used for nontraumatic procedures.When post­
for injection, it sometimes is difficultto select an ideal drug operative pain is considered likely,0.5% bupivacaine (for 8
for a given patient. Many dentists simply deal with this by to 12 hours of soft tissue anesthesia [via nerve block]) is
using one local anesthetic for all procedures, regardless of suggested.
their duration. For example,the dentist may elect to use 2% For patients in whom postoperative anesthesiarepresents
lidocainewith 1: 100,000epinephrine for procedures lasting a potential risk,a shorter-duration anesthetic should be con­
5 to 10 minutes and for procedures involving90 minutes of sidered. These patients include younger children, the older­
treatment time. Although the duration of pulpal anesthesia old patient, and the physically or mentally disabled, who
achievablewith this drug, in idealcircumstances,may permit might accidentally bite or chew their lips or tongue, and
pain-free treatment in both these instances,the patient who persons unable to miss a meal (e.g.,those with type 1 diabe­
requires only 10 minutes of pulpal anesthesia will remain tes) because of residual soft tissue anesthesia. For these
anesthetized unnecessarily for an additional 3 to 5 hours patients, 3% mepivacaine is recommended for use in short
(soft tissues), whereas the patient requiring 90 minutes of procedures. However in situations in which these patients
pulpal anesthesiawill likelyexperiencepain toward the end require a more profound and/or longer duration of pulpal
of the procedure. anesthesia, use of a local anesthetic containing a vaso­
A rational approach to selection of an appropriate local constrictor is necessary.The introduction of the local anes­
anesthetic for a patient includes consideration of several thesia reversalagent, phentolamine mesylate(Oraverse),has
factors: (1) the length of time for which pain control is made it possible to significantly shorten the duration of
necessary; (2) the need for posttreatment pain control; residual soft tissue anesthesia, thereby minimizing the risk

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CHAPTER 4 Clinical Action of Specific Agents 73

of accidental self-inflicted soft tissue injury (e.g., biting of


the lip or tongue).82-84 Reversal of soft tissue anesthesia in BOX 4-4 Factors in Selection of a Local Anesthetic
discussed in Chapter 20.
for a Patient
A third factor in choosing a local anesthetic is the require­ 1. Length of time pain control is necessary
ment for hemostasis during the procedure. Anesthetic solu­ 2. Potential need for posttreatment pain control
tions containing epinephrine in a 1:50,000 or 1: 100,000 3. Possibility of self-mutilation in the postoperative
concentration are recommended, via local infiltration into period
the surgical site, when hemostasis is considered necessary. 4. Requirement for hemostasis
More dilute epinephrine formulations (e.g., 1:200,000, 5. Presence of any contraindications (absolute or
1:400,000) are not effective for hemostasis, nor is levonor­ relative) to the local anesthetic solution selected for
defrin or felypressin. administration
A fourth factor in the selection of a local anesthetic
involves the presence of any contraindications to use of the
selected local anesthetic (see Table 4-2).
Absolute contraindications require that the offending
drug(s) is not administered to the patient under any condi­ TABLE 4-18
tion. The risk that a life-threatening situation will arise is Proprietary Names of Injectable Local Anesthetics
unacceptably elevated. Most absolute contraindications to (United States)
local anesthetic administration are, in fact, medical contra­ Articaine HCl Articadent, Orabloc, Septocaine,Zorcaine
indications to the delivery of elective dental care (e.g., the BupivacaineHCl Marcaine,Vivacaine
patient is too ill to tolerate dentistry). However, one absolute LidocaineHCl Lignospan,Octocaine, Xylocaine
contraindication to local anesthetic administration does MepivacaineHCl Carbocaine, Isocaine,Polocaine,Scandanest
exist: true, documented reproducible allergy. Although the Prilocaine HCl Citanest
incidence of "alleged" local anesthetic allergy is high, true,
documented and reproducible allergy is an extremely rare
occurrence with amide local anesthetics. Management of
alleged and documented allergy to local anesthetics is dis­
References
cussed in Chapter 18.
1. Malamed SF: Handbook of local anesthesia, St Louis, 1980,
In cases of a relative contraindication, it is preferable to
Mosby.
avoid administration of the drug in question because the risk
2. Malamed SF: Buffering local anesthetics in dentistry, ADSA
that an adverse reaction will occur is increased. An alterna­ Pulse 44:8--9, 2011.
tive drug that is not contraindicated is recommended. 3. MeechanJG:Infiltration anesthesiain the mandible, Dent Clin
However, if an acceptable alternative is not available, the North Am 54:621-629, 2010.
drug in question may be used, but judiciously, with the 4. Iwatsubo T, Hirota N, Ooie T, et al: Prediction of in vivo drug
minimum dose that will provide adequate pain control metabolism in the human liverfrom in vitro metabolism data,
administered. One example of a relative contraindication is Pharmacol Ther 73:147-171, 1997.
the presence of atypical plasma {pseudo )cholinesterase, 5. Thompson P, Melmon K, Richardson J, et al: Lidocaine phar­
which decreases the rate of biotransformation of ester local macokineticsin advancedheart failure,liver disease,and renal
anesthetics. Amides may be used without increased risk in failure in humans, Ann Intern Med 78:499, 1973.
6. Haase A. ReaderA, Nusstein J, BeckM, Drum M. Comparing
these patients. Contraindications (both absolute and rela­
anestheticefficacyof articaine versuslidocaineas a supplemen­
tive) are reviewed in Chapter 10.
tal buccal infiltration of the mandibular first molar after an
Box 4-4 summarizes the criteria used in selection of a inferior alveolar nerve block, J Amer Dent Assoc 139:1228-
local anesthetic for administration to a given patient at a 1235, 2008.
given dental appointment. 7. Malamed SF: Sedation: a guide to patient management, ed 4,
Table 4-18 lists the proprietary names of injectable local St Louis, 2003, Mosby.
anesthetics available in the United States (as of November 8. Wilson AW,Deacock S, Downie IP,et al:Allergyto local anes­
2011). thetic: the importance of thorough investigation, Br Dent J
The local anesthetic armamentarium for a dentist or 188:320--322, 2000.
dental hygienist therefore should include drugs of varying 9. Covino BG: Clinical pharmacology of local anesthetic agents.
durations of action, such as the selection that follows. A In Cousins MJ, Bridenbaugh PO, editors: Neural blockade in
clinicalanesthesiaand management of pain, ed 2, Philadelphia,
minimum of two drugs is recommended for most offices.
1988, JB Lippincott.
Amides are preferred to esters whenever possible:
10. Prescribing information: Ravocaineand Novocain with Levo­
1. Short-duration pulpal anesthetic {=30 minutes) phed, NewYork, 1993, Cook-Waite,SterlingWinthrop.
2. Intermediate-duration pulpal anesthetic (=60 minutes) 11. Moore PA. Hersh EV: Local anesthetics: pharmacology and
3. Long-duration pulpal anesthetic (90 or more minutes) toxicity,Dent Clin North Am 54:587-599, 2010.
4. Topical anesthetic for tissue preparation before injection 12. Prescribinginformation: 2% XylocaineDental,York,Pa,March
of local anesthetic 2009, Dentsply Pharmaceutical.

www.ShayanNemoodar.com
74 PARTI The Drugs

13. BrownRS,PaluvoiS,ChoksiS,et al:Evaluatinga dental patient 35 Garisto GA,GaffenAS,LawrenceHP,et al: Occurrence of par­
for local anesthesia allergy,Comp Contin Educ Dent 23:225- esthesia after dental local anesthetic administration in the
228, 131-132, 134, 140,2002. United States,J Am Dent Assoc 141:836-844,2010.
14. Jackson D, Chen AH, Bennett CR: Identifying true lidocaine 36. Pogrel MA: Permanent nerve damage from inferior alveolar
allergy,J Am Dent Assoc 125:1362-1366,1994. nerve blocks-an update to include articaine, J Calif Dent
15. Sindel LJ, deShazo RD: Accidents resulting from local Assoc35:271-273,2007.
anesthetics: true or false allergy?Clin Rev Allergy9:379-395, 37. van Oss GE, Vree TB, Baars AM, et al: Pharmacokinetics,
1991. metabolism, and renal excretionof articaine and its metabolite
16. BallIA:Allergicreactions to lignocaine,Br Dent J 186:524--526, articainic acid in patients after epidural administration, Eur J
1999. Anaesthesiol6:19-56, 1989.
17. Baluga JC: Allergyto local anaesthetics in dentistry: myth or 38. van Oss GE, Vree TB, Baars AM, et al: Clinical effects and
reality?RevAlergMex 50:176-181,2003. pharmacokinetics of articainic acid in one volunteer after
18. ThyssenJP,Menne T,ElberlingJ,et al:Hypersensitivityto local intravenous administration, Pharm Weekbl (Sc) 10:284--286,
anaesthetics-update and proposal of evaluation algorithm, 1988.
Contact Dermatitis 59:69-78, 2008. 39. VreeTB,BaarsAM,van Oss GE,et al:High performance liquid
19. YoungER,Mason DR,SasoMA,et al: Some clinicalproperties chromatography and preliminary pharmacokinetics of artic­
of Octocaine 200 (2 percent lidocaine with epinephrine aine and its 2-carboxy metabolite in human serum and urine,
1:200,000),J Can Dent Assoc55:987-991, 1989. J Chromatogr 424:240-444, 1988.
20. BuckleyJA,Ciancio SG,McMullenJA:Efficacyof epinephrine 40. Prescribing information: Septocaine, Louisville, Colo, 2011,
concentration in local anesthesia during periodontal surgery, Septodont Inc.
J Periodontol 55:653-657, 1984. 41. Malamed SF,Gagnon S, Leblanc D: Safetyof articaine: a new
21. DeToledo JC: Lldocaine and seizures, Ther Drug Monit amide local anesthetic, J Am Dent Assoc 132:177-185,2001.
22:320-322,2000. 42. Malamed SF,Gagnon S, LeblancD: Articaine hydrochloride in
22. Malamed SF,YagielaJ: Local anesthetics. In ADA Guide to pediatric dentistry: safety and efficacyof a new amide-type
Dental Therapeutics, Chicago, Ill, 1998, American Dental local anesthetic, Pediatr Dent 22:307-311,2000.
Association. 43. Malamed SF,Gagnon S, LeblancD: Efficacyof articaine: a new
23. GeddesIC: Metabolism oflocal anesthetic agents,Int Anesthe­ amide local anesthetic, J Am Dent Assoc 131:535--642,2000.
siol Clin 5:525-549, 1967. 44. Donaldson D,James-PerdokL,Craig BJ,et al:A comparison of
24. Severinghaus JW, Xu F-D, Spellman MJ: Benzocaine and Ultracaine DS (articaine HCl) and Citanest Forte (prilocaine
methernoglobin: recommended actions, Anesthesiology 74: HCl) in maxillary infiltration and mandibular nerve block,
385-386, 1991. J Can Dent Assoc53:38--42,1987.
25. Schroeder TH, Dieterich HJ, Muhlbauer B: Methemoglobin­ 45. Knoll-KohlerE, Rupprecht S:Articaine for local anaesthesiain
ernia after maxillary block with bupivacaine and additional dentistry: a lidocaine controlled double blind cross-overstudy,
injection of lidocaine in the operative field,Acta Anaesthesiol Eur J Pain 13:59--63,1992.
Scand 43:480-482, 1999. 46. Septodont Inc., NA: Personal communications, May 2011.
26. Wilburn-Goo D, Lloyd LM: When patients become cyanotic: 47. Schulze-Husmann M: Experimental evaluation of the new
acquired methemoglobinemia, J Am Dent Assoc 130:626-631, local anestheticUltracaine in dental practice, doctoral disserta­
1999. tion, Bonn, 1974,Universityof Bonn.
27. de Jong RH: Local anesthetics,St Louis, 1994,Mosby. 48. Cliniciansguide to dental products and techniques,Septocaine.
28. Akerman B,Astrom A, RossS, et al: Studieson the absorption, CRANewsletterJune 2001.
distribution, and metabolism of labeled prilocaine and lido­ 49. Kanaa MD, Whitworth JM, Corbett IP, et al: Articaine buccal
caine in some animal species,Acta Pharmacol Toxicol24:389- infiltration enhances the effectiveness of lidocaine inferior
403, 1966. alveolarnerve block, Int Endod J 42:238--246,2009.
29. Foldes FF,MolloyR, McNallPG, et al: Comparison of toxicity 50. MeechanJG:Infiltration anesthesiain the mandible, Dent Clin
of intravenously given local anesthetic agents in man, JAMA North Am 54:621--629,2010.
172:1493-1498,1960. 51. Yonchak T, Reader A, Beck M, et al: Anesthetic efficacy of
30. EnglessonS, Eriksson E, Ortengren B:Differencesin tolerance infiltrations in mandibular anterior teeth, Anesth Prog 48:55-
to intravenous Xylocaine and Citanest, Acta Anaesthesiol 60, 2001.
Scand Suppl 16:141-145,1965. 52. Meechan JG, Ledvinka JI: Pulpal anaesthesia for mandibular
31. Deriksson E, Granberg PO: Studies on the renal excretion of central incisor teeth: a comparison of infiltration and intraliga­
Citanest and Xylocaine,ActaAnaesthesiolScand Suppl 16:79- mentary injections, Int Endod J 35:629--634,2002.
85, 1985. 53. Kanaa MD, Whitworth JM, Corbett IP, et al: Articaine and
32. Smith DW, Peterson MR, DeBerard SC: Local anesthesia: lidocaine mandibular buccal infiltration anesthesia:a prospec­
topical application, local infiltration, and fieldblock, Postgrad tive randomized double-blind cross-over study, J Endod
Med 106:27--60,64--66,1999. 32:296-298,2006.
33. Akinturk S, Eroglu A: A clinical comparison of topical piroxi­ 54. Robertson D,Nusstein J,ReaderA, et al:The anesthetic efficacy
cam and EMLAcream for pain reliefand inflammation in laser of articaine in buccalinfiltration of mandibular posterior teeth,
hair removal, LasersMed Sci 24:535-538,2009. J Am Dent Assoc 138:1104--1112,2007.
34. Haas DA, Lennon D: A 21 year retrospective study of 55. Haase A, Reader A, Nusstein J, et al: Comparing anesthetic
reports of paresthesia following local anesthetic admini­ efficacyof articaine versus lidocaine as a supplemental buccal
stration, J Can Dent Assoc 61:319-320, 323-326, 329-330, infiltration of the mandibular first molar after an inferior alve­
1995. olar nerve block, J Am Dent Assoc 139:1228--1235,2008.

www.ShayanNemoodar.com
CHAPTER 4 ClinicalActionof SpecificAgents 75

56. Jakobs W: Status of dental anesthesia in Germany, Anesth Prog 71. Alston TA: Antagonism of sulfonamides by benzocaine and
36:10--212, 1989. chloroprocaine,Anesthesiology76:375--476,1992.
57. Deutscher Dentalmarkt Jahresbericht (DDM) 2010 (German 72. Adriani J, Zepernick R: Clinicaleffectivenessof drugs used for
Dental Market Annual Report 2010) GfK HealthCare, Nurem­ topical anesthesia,JAMA188:93,1964.
berg, Germany. 73. TaddioA: Pain management for neonatal circumcision,Paedi­
58. Malamed SF: Handbook of local anesthesia, ed 4, St Louis, atr Drugs 3:101-111,2001.
1997, Mosby, pp 63-64. 74. VanscheidtW,SadjadiZ, LillieborgS:EMLAanaestheticcream
59. Articaine, epinephrine: contraindications/precautions, MD for sharp leg ulcer debridement: a review of the clinical evi­
Consult. Available at: http://www.mdconsult.com/php/25067 dence for analgesic efficacyand tolerability, Eur J Dermatol
9983-2/homepage. Revised April 21, 2010. Accessed May 24, 11:20--96,2001.
2011. 75. Wright VC:Vulvarbiopsy:techniques for reducing patient dis­
60. Jakobs W: Actual aspects of dental anesthesia in Germany. Pre­ comfort, Adv Nurse Pract 9:17-60, 2001.
sented at the 10th International Dental Congress on Modern 76. EMLA,MD Consult.Availableat: http://www.mdconsult.com/
Pain Control, IFDAS, Edinburgh, Scotland, UK, June 2003. php/250679983-2/homepage.RevisedMay 12,2010.Accessed
61. Prescribing information: Bupivacaine HCl, Lake Forest, Ill, May 24, 2011.
November 2009, Hospira, Inc. 77. Bernardi M, SeccoF,BenechA:Anestheticefficacyof a eutectic
62. Moore PA: Bupivacaine: a long-lasting local anesthetic for den­ mixture of lidocaine and prilocaine (EMLA) on the oral
tistry, Oral Surg 58:369, 1984. mucosa: prospective double-blind study with a placebo,
63. Acute Pain Management Guideline Panel: Acute pain manage­ Minerva Stomatol 48:9-43, 1999.
ment: operative or medical procedures and trauma. Clinical 78. Munshi AK,Hegde AM, Latha R: Use of EMLA:is it an injec­
practice guideline. AHCPR Publication Number 92-0032, tion free alternative?J Clin Pediatr Dent 25:215-219,2001.
Rockville, Md, 1992, Agency for Health Care Policy and 79. Franz-Montan M, Ranali J, RamacciatoJC, et al: Ulceration of
Research, Public Health Service, U.S. Department of Health gingivalmucosa after topical application of EMLA:report of
and Human Services. four cases,Br Dent J 204:133-134,2008.
64. Oxford League Table of Analgesics in Acute Pain: Bandolier 80. Nayak R, Sudha P: Evaluation of three topical anaesthetic
Website. Available at: http://www.medicine.ox.ac.uk/bandolier/ agents against pain: a clinicalstudy,Indian J Dent Res 17:155-
booth/painpag/acutrev/analgesicsflftab.html. Accessed May 24, 160,2006.
2011. 81. Universityof Buffalo,The State Universityof NewYork:Nasap
65. Hargreaves KM, Keiser K: Development of new pain manage­ spray may end dental needle injections for upper teeth repair.
ment strategies, J Dent Educ 66:113-121, 2002. Availableat: www.buffalo.edu/news/9911.AccessedFebruary
66. Malamed SF: Handbook of local anesthesia, ed 5, St Louis, 17,2009.
2003, CV Mosby, pp 74-75. 82. Moore PA, Hersh EY, Papas AS, et al: Pharmacokinetics
67. Adriani J, Campbell D: Fatalities following topical application of lidocaine with epinephrine following local anesthesia
of local anesthetics to mucous membranes, JAMA 162:1527, reversal with phentolamine mesylate,Anesth Prog 55:40--48,
1956. 2008.
68. Jeske AH, Blanton PL: Misconceptions involving dental local 83. Hersh EY,Moore PA, Papas AS, et al, Soft Tissue Anesthesia
anesthesia. Part 2. Pharmacology, Texas Dent J 119:310--314, RecoveryGroup: Reversalof soft-tissue local anesthesia with
2002. phentolamine mesylate in adolescents and adults, J Am Dent
69. Rosivack RG, Koenigsberg SR, Maxwell KC: An analysis of the Assoc 139:1080--1093,2008.
effectiveness of two topical anesthetics, Anesth Prog 37:290-- 84. TavaresM, Goodson JM,Studen-PavlovichD, et al, SoftTissue
292, 1990. Anesthesia ReversalGroup: Reversalof soft-tissue local anes­
70. Patterson RP, Anderson J: Allergic reactions to drugs and bio­ thesia with phentolamine mesylate in pediatric patients, J Am
logic agents, JAMA 248:2637-2645, 1982. Dent Assoc 139:1095-1104,2008.

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IN THIS PART
Chapter 5 The Syringe
Chapter 6 The Needle
Chapter 7 The Cartridge
Chapter 8 Additional Armamentarium
Chapter 9 Preparation of the Armamentarium

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PART

The Armamentarium

The equipment necessary for the administration of local anesthetics is introduced and discussed in
this section. This includes the syringe, needle, and local anesthetic cartridge, as well as additional
items of equipment. In addition to providing a description of the armamentarium, each chapter
reviews the proper care and handling of the equipment and problems that may be encountered
with its use. A discussion of the proper technique for assembling and disassemblingthe equipment
follows.
The introduction of computer-controlled local anesthetic delivery (C-CLAD) systems has
enhanced the delivery of local anesthetic for many dentists and their patients. These devices have
demonstrated great utility in the painless delivery of dental local anesthetics and are described in
detail in this section.

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I

The Syringe
' I •I

The syringeis one of three essentialcomponents of the local The needle then passes into the barrel, where it penetrates
anesthetic armamentariwn (others include the needle and the diaphragm of the local anesthetic cartridge. The needle
the cartridge). It is the vehiclewhereby the contents of the adaptor (screw hub or convertible tip) is removable and
anesthetic cartridge are deliveredthrough the needle to the sometimes is discarded inadvertently along with the dispos­
patient. able needle.
The aspirating syringehas a devicesuch as a sharp, hook­
shaped end {oftencalledthe harpoon) attached to the piston
TYPES OF SYRINGES
that is used to penetrate the thick silicone rubber stopper
Eight types of syringes for local anesthetic administration (bung) at the opposite end of the cartridge (from the needle).
are available for use in dentistry today. They represent a Provided the needle is of adequate gauge, when negative
considerableimprovement over the local anesthetic syringes pressure is exerted on the thwnb ring by the administrator,
formerly used. These various types of syringes are listed in blood will enter into the needle and will be visible in the
Box 5-1. cartridge if the needle tip rests within the lwnen of a blood
Syringesthat do not permit aspiration (i.e.,nonaspirating vessel. Positive pressure applied to the thumb ring forces
syringes) are not discussed because their use unacceptably local anesthetic into the needle lwnen and the tissueswher­
increases the risk of inadvertent intravascular drug admin­ everthe needle tip lies.The thumb ring and finger grips give
istration. Use of aspirating dental syringes (capable of the the administrator added control over the syringe.Almost all
aspiration of blood) represents the standard of care. syringe manufacturers provide syringeswith both "regular"
American Dental Association criteria for acceptance of and "small" thumb rings (Fig. 5-2). Most metallic, breech­
local anesthetic syringesinclude the following'P; loading, aspirating syringes are constructed of chrome­
1. They must be durable and able to withstand repeated plated brass and stainlesssteel.
sterilization without damage. (If the unit is disposable, Advantages and disadvantages of the metallic, breech­
it should be packaged in a sterile container.) loading, aspirating syringe are listed in Box 5-2.
2. They should be capable of accepting a wide variety of
cartridges and needles of different manufacture, and Breech-Loading. Plastic, Cartridge-Type. Aspirating. A
should permit repeated use. plastic, reusable,dental aspirating syringe is availablethat is
3. They should be inexpensive,self-contained,lightweight, both autoclavable and chemically sterilizable.With proper
and simple to use with one hand. care and handling, this syringe may be used for multiple
4. They should provide for effectiveaspiration and be anesthetic administrations before it is discarded.Advantages
constructed so that blood may be easilyobserved in the and disadvantagesof the plastic, reusable,aspirating syringe
cartridge. are listed in Box 5-3.

Breech-Loading, Metallic, cartridge-Type, Self-Aspirating.


Nondisposable Syringes Potential hazards of intravascular administration of local
Breech-Loading. Metallic. Cartridge-Type. Aspirating. The anesthetics are great and are discussed more fully in
breech-loading, metallic, cartridge-type syringe (Fig.5-1) is Chapter 18.The incidence of positive aspiration may be as
the most commonly used in dentistry. The term breech­ high as 10% to 15% with some injection techniques.3 It is
loading impliesthat the cartridge is inserted into the syringe accepted by the dental profession that an aspiration test
from the side of the barrel of the syringe. The needle is before administration of a local anesthetic drug is of great
attached to the barrel of the syringe at the needle adaptor. importance. Unfortunately, it is abundantly clear that in
78

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CHAPTER 5 The Syringe 79

BOX 5-1 Syringe Types Available in Dentistry BOX 5-2 Advantages and Disadvantages of the
Metallic., Breech-Loading, Aspirating Syringe
1. Nondisposable syringes:
a. Breech-loading, metallic, cartridge-type, Advantages Disadvantages
aspirating Visible cartridge Weight (heavier than
b. Breech-loading, plastic, cartridge-type, aspirating Aspiration with one hand plastic syringe)
c. Breech-loading, metallic, cartridge-type, Autoclavable Syringe may be too big for
self-aspirating Rust resistant small operators
d. Pressure syringe for periodontal ligament Long lasting with proper Possibility of infection
injection maintenance with improper care
e. Jet injector ("needle-less" syringe)
2. Disposable syringes
3. "Safety" syringes
4. Computer-controlled local anesthetic delivery BOX 5-3 Advantages and Disadvantages of the
systems Plastic., Reusable, Aspirating Syringe
Advantages Disadvantages
Plastic eliminates metallic, Size (may be too big for
clinical look small operators)
Lightweight: provides better Possibility of infection
Piston with
harpoon "feel" during injection with improper care
Cartridge is visible Deterioration of plastic
Aspiration with one hand with repeated
Rust resistant autoclaving
Long lasting with proper
maintenance
Lower cost
Syringe Thumb ring
barrel

B Figure 5-2. Harpoon-type aspirating syringes with small and


large thumb rings.
Figure 5-1. A, Breech-loading, metallic, cartridge-type syringe;
assembled. B, Disassembled local anesthetic syringe.

TABLE 5-1
actual clinical practice, too little attention is paid to this Percentages of Dentists Who Aspirate Before Injection
procedure (Table 5-1).
INFERIORALVEOLAR MAXILLARY
With commonly used breech-loading, metallic, cartridge­ NERVEBLOCK INFILTRATION
type syringes, an aspiration test must be carried out pur­
Frequency Percent Cumulative Percent Cumulative
posefully by the administrator before or during drug
deposition. The key word here is purposefully. However, as Always 63.2 40.2
demonstrated in Table 5-1, many dentists do not purpose­ Sometimes 14.7 77.9 24.1 64.3
Rarely 9.2 87.1 18.4 82.7
fully perform an aspiration test before injection of the anes­
Never 12.9 17.3
thetic drug. 4

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80 PARTII The Armamentarium

Toincreasethe ease of aspiration, self-aspiratingsyringes The self-aspirating syringe was introduced into the
have been developed (Fig. 5-3). These syringes use the United States in 1981.After an initial period of enthusiasm,
elasticityof the rubber diaphragm in the anesthetic cartridge the popularity of this syringe decreased. Some dentists
to obtain the necessary negative pressure for aspiration. believed that the self-aspirating syringe did not provide
The diaphragm rests on a metal projection inside the syringe the same reliabledegree of aspiration that was possiblewith
that directs the needle into the cartridge (Fig.5-4). Pressure the harpoon-aspirating syringe. It has been demonstrated,
acting directly on the cartridge through the thumb disc however,that this syringe does in fact aspirate as reliablyas
(Fig. 5-5) or indirectly through the plunger shaft distorts the harpoon-aspirating syringe."? The notion can occur
(stretches) the rubber diaphragm, producing positive pres­ that aspiration may not be as reliablewith the self-aspirating
sure within the anesthetic cartridge. When that pressure is syringe because the administrator simply has to depress
released,sufficientnegativepressure developswithin the car­ and release the thumb ring to aspirate, rather than pulling
tridge to permit aspiration. The thumb ring produces twice back on the thumb ring. Moving the thumb off the thumb
as much negativepressure as the plunger shaft. The use of a ring and onto the thumb disc for aspiration has been
self-aspirating dental syringe permits easy performance of mentioned by many dentists as uncomfortable for them.
multiple aspirations throughout the period of local anes­ Although this is the preferred means of obtaining a satisfac­
thetic deposition. tory aspiration test with these syringes, pressure adequate
for aspiration may be obtained by simply releasingthe pres­
sure of the thumb on the thumb ring. Second-generation
self-aspiratingsyringeshave eliminated the thumb disc.
The major factor influencing ability to aspirate blood is
not the syringe,but the gauge of the needle being used.7 In
addition, most doctors using the harpoon-aspirating syringe
tend to overaspirate,that is,they retract the thumb ring back
too far and with excessiveforce (and, on occasion,disengage
the harpoon from the stopper). These doctors feel more
insecure with the self-aspirating syringe. Proper technique
of aspiration is discussed in Chapter 11. Advantages and
disadvantages of the metallic, self-aspirating syringe are
listed in Box 5-4.

Pressure Syringes. Introduced in the late 1970s,pressure


syringesbrought about a renewedinterest in the periodontal
ligament (PDL) injection (also known as the intraligamen­
tary injection [ILI]). Discussedin Chapter 16,the PDLinjec­
tion, although usable for any tooth, helped make it possible
to achieve more reliable pulpal anesthesia of one isolated
tooth in the mandible where, in the past, nerve block anes­
Figure 5-3. Self-aspiratingsyringe. thesia (e.g.,inferior alveolarnerve block [IANB],Gow-Gates

Figure 5-5. Pressure on the thumb disc (arrow) increasespres­


Figure 5-4. A metal projection within the barrel depressesthe sure within the cartridge. Releaseof pressure on the thumb disc
diaphragm of the local anesthetic cartridge. produces the self-aspirationtest.

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CHAPTER 5 The Syringe 81

THE WILCOX-JEWETT OBTUNDER.


BOX 5-4 Advantages and Disadvantages of the LEE s. SMITH & SON, PITTSBURG.
Metallic, Self-Aspirating Syringe
Advantages Disadvantages
Cartridge visible Weight ~~--------
Easierto aspirate with Feelingof "insecurity'' for
small hands doctors accustomed to
Autoclavable harpoon-type syringe
Rust resistant Finger must be moved
Long lasting with proper from thumb ring to
maintenance thumb disc to aspirate PATENT APPLIEDFOR.
The Wilcox-Jewett Obtunder, about% Actual Size.
Piston is scored (indicates Possibilityof infection
volume of local with improper care Figure 5-7. Pressure syringe (1905) designed for a periodontal
anesthetic administered) injection.

Figure 5-8. Second-generationsyringefor periodontal ligament


(PDL) injection.
Figure 5-6. Original design of pressure syringe for periodontal
ligament (PDL) injection or intraligamentary (ILI) injection.

Pressure syringes offer advantagesover the conventional


syringe when used for PDL injections because their trigger
mandibular nerve block), with its attendant prolonged soft delivers a measured dose of local anesthetic and enables a
tissue (e.g.,lingual) anesthesia,was necessary. relativelyphysicallyweakadministrator to overcomethe sig­
The original pressure devices,Peripress (UniversalDental nificant tissue resistanceencountered when the technique is
Implements, Edison, NJ) and Ligmaject (IMA Associates, administered properly.This mechanical advantage may also
Bloomington, Ind) (Fig. 5-6), were modeled after a device prove to be detrimental if the administrator deposits the
that was availablein dentistry in 1905-the Wilcox-Jewett anesthetic solution too quickly (<20 sec/0.2 mL dose). All
obtunder (Fig. 5-7). These first-generation devices,using a pressure syringes completely encase the glass dental car­
pistol grip, are somewhat larger than the newer, pen-grip tridge with plastic or metal, thereby protecting the patient in
devices (Fig. 5-8). Although "special"syringes such as these the unlikely event that the glass cartridge cracks or shatters
are not necessary for a successful PDL injection, several during injection. The original pressure syringes looked
advantages are associated with their use, not the least of somewhat threatening, having the appearance of a gun (see
which is the mechanical advantage they provide the admin­ Fig. 5-6). Newer devices are smaller and are much less
istrator, making the local anesthetic easier to administer. intimidating.
This same mechanical advantage,however,makes the injec­ Probably the greatest disadvantage of using the pressure
tion somewhat "too easy" to administer, leading to "too syringeis its cost; most are priced at considerablymore than
rapid" injection of the anesthetic solution and patient dis­ US $200 (November 2011). For this reason among others,
comfort both during the injection and later,when the anes­ it is recommended that pressure devices be considered for
thetic has worn off. However, when used slowly, as use only after the PDL injection has been found to be inef­
recommended by manufacturers, pressure syringes are of fectiveafter severalattempts with a conventionalsyringeand
some benefit in administration of this valuabletechnique of needle.Box5-5 lists the advantagesand disadvantagesof the
anesthesia. pressure syringe.

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82 PARTII The Armamentarium

BOX 5-5 Advantages and Disadvantages of the BOX 5-6 Advantages and Disadvantages of the
Pressure Syringe Jet Injector
Advantages Disadvantages Advantages Disadvantages
Measured dose Cost Does not require use of Inadequate for pulpal
Overcomestissue resistance Easyto inject too rapidly needle (recommended anesthesia or for regional
Nonthreatening (new Threatening (original for needle phobics) block
devices) devices) Deliversvery small Some patients are
Cartridges protected volumes of local disturbed by the jolt of
anesthetic (0.01 to the injection.
0.2 mL) Cost
Used in lieu of topical May damage periodontal
anesthetics tissues

anesthetic. It is calibrated to deliver 0.05 to 0.2 mL of solu­


tion at 2000 psi.
The primary purpose of the jet injector is to obtain
topical anesthesia before insertion of a needle. In addition,
it may be used to obtain mucosal anesthesia of the palate.
Regionalnerve blocks or supraperiosteal injections are still
necessaryfor complete anesthesia.The jet injector is not an
adequate substitute for the more traditional needle and
syringe in obtaining pulpal or regional block anesthesia.
Figure 5-9. SyriJet needleless injector. (Courtesy Mizzy Inc.,
Cherry Hill, NJ.) Additionally,many patients dislikethe feelingthat accompa­
nies use of the jet injector, as well as the possible postinjec­
tion soreness of soft tissue that may develop even with
proper use of the device.Topicalanesthetics, applied prop­
erly,serve the same purpose as jet injectors at a fraction of
the cost (SyriJet Mark II, US $1950 [November 2011]*;
MadaJet XL Dental, US $600 [November 2011]) and with
minimum risk.Advantagesand disadvantagesof jet injectors
are listed in Box 5-6.

Disposable Syringes
Plastic disposable syringes are available in a variety of
sizeswith an assortment of needle gauges.Most often they
are used for intramuscular or intravenous drug admini­
Figure 5-10. MadaJet.
stration, but they also may be used for intraoral injection
(Fig.5-11).
These syringes contain a Luer-Lok screw-on needle
Jet Injector. In 1947 Figge and Scherer introduced a new attachment with no aspirating tip. Aspiration can be accom­
approach to parenteral injection-the jet or needle-less plished by pulling back on the plunger of the syringebefore
injection.8 This represented the first fundamental change in or during injection. Becausethere is no thumb ring, aspira­
the basic principles of injection since 1853,when Alexander tion with the plastic disposable syringe requires the use of
Wood introduced the hypodermic syringe.The first report both hands. In addition, these syringesdo not accept dental
of the use of jet injections in dentistry was published in 1958 cartridges. The needle, attached to the syringe, must be
by Margetis and associates.9 Jet injection is based on the inserted into a vial or cartridge of local anesthetic drug and
principle that liquids forced through very small openings, an appropriate volume of solution withdrawn. Care must be
calledjets, at very high pressure can penetrate intact skin or taken to avoid contaminating the multi-use vial during this
mucous membrane (visualize water flowing through a procedure. Two- and 3-mL syringes with 25- or 27-gauge
garden hose that is being crimped). The most frequently needlesare recommended when the systemis used for intra­
used jet injectors in dentistry are the SyriJetMark II (Mizzy oral local anesthetic administration.
Inc., Cherry Hill, NJ) (Fig. 5-9) and the MadaJet (Mada
Medical Products Incorporated, Carlstadt, NJ) (Fig. 5-10). *Mizzy Inc., 616 Hollywood Ave., Cherry Hill, NJ 08002; 1-800-663-4700;
The Syrilet holds any 1.8-mL dental cartridge of local www.keystoneind.com.

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CHAPTER5 The Syringe 83

c·-
l/rr rr/r 11rp rrqr11111
<?' .•• Col...,_
A

Figure 5-11. Plastic disposable syringe.

B
BOX 5-7 Advantages and Disadvantages of the
Figure 5-12. A. UltraSafety Plus XL aspirating syringe, ready for
Disposable Syringe
injection. B, UltraSafety Plus XL aspirating syringe; needle sheathed
Advantages Disadvantages to prevent needle-stick injury.
Disposable,single use Does not accept prefilled
Sterileuntil opened dental cartridges
Lightweight(may feel Aspiration difficult
awkwardto the first-time (requires two hands) BOX 5-8 Advantages and Disadvantages of the
user; tactile sensation Safety Syringe
better) Advantages Disadvantages
Disposable,single use Cost: more expensivethan
Sterile until opened reusable syringe
Lightweight(better tactile May feel awkwardto a
The plastic,disposable,non-cartridge-containing syringe sensation) first-time user
is not recommended for routine use. Its use should be
considered only when a traditional syringe is not available
or cannot be used. This system is also practical when
diphenhydramine HCl is used as a local anesthetic in the needle. Upon completion of the injection, the entire
cases of presumed local anesthetic allergy (see Chapter 18). syringe is discarded into the proper receptacle (e.g., sharps
Box 5-7 lists the advantages and disadvantages of the dis­ container).
posable syringe. Dental safety syringes are designed as single-use items,
although they permit reinjection. Reloadingthe syringewith
Safety Syringes a second anesthetic cartridge and reinjecting with the same
Recentyears have seen a move toward the development and syringe is discouraged because this obviates the important
introduction of safety syringes in both medicine and den­ safetyaspect of the device.
tistry. Safety syringes minimize the risk of an accidental In 2000, Cuny and associatesevaluatedfour dental safety
needle-stick injury occurring to a dental health provider syringesystems-Safe-Mate needle system (Septodont Inc.),
with a contaminated needle after administration of a local Safety Plus syringe (Septodont Inc.), UltraSafe syringe
anesthetic. These syringespossessa sheath that "locks"over (Septodont Inc.), and Hypo Safety syringe (Dentsply MPL
the needle when it is removed from the patient's tissues, Technologies,Franklin Park, lli)---over a I-year period at
preventing accidental needle-stick. a U.S. dental school." Their finding was that using these
Devicessuch as the UltraSafetyPlus XL*and the 1 Shot Food and Drug Administration (FDA)-approved devices
Safety Syringe+ were available as of January 2011. The resulted in an initial increase in needle-stick injuries. They
UltraSafety Plus XL aspirating syringe system contains a stated that hands-on training, monitoring, and follow-up
syringebody assemblyand a plunger assembly(Fig.5-12, A). reminders appeared to be effective in reducing injuries
Once the syringe is properly assembled and the injection associatedwith the changefrom traditional to safetyneedles.
administered,the syringemay be made "safe"with one hand Advantages and disadvantages of the safety syringe are
by gently moving the index and middle fingers against the listed in Box 5-8.
front collar of the guard (Fig. 5-12, B). Once "guarded:'
the now contaminated needle is "safe,"so that it is virtually Computer-Controlled Local Anesthetic
impossible for dental health providers to be injured with Delivery {C-CLAD) Systems
The standard dental syringe described previouslyis a simple
mechanicalinstrument that datesbackto 1853, when Charles
*illtraSafety Plus XL, Septodont Inc., 245C Quigley Blvd., New Castle,
DE 19720;1-800-872-8305;www.septodontinc.com.
Pravaz patented the first syringe.11The dental syringe is a
t 1 Shot SafetySyringe,Sultan Chemists, Englewood,NJ; 1-800-637-8582; drug deliverydevice requiring that the operator simultane­
www.sultanintl.com. ously attempt to control the variables of drug infusion and

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84 PARTII The Armamentarium

Figure 5-14. Foot-activated control of The Wand.

Figure 5-13. Computer-controlled local anesthetic delivery


system-The Wand.

the movement of a penetrating needle.The operator's inabil­


ity to precisely control both of these activities during an
injection can compromise an injection technique. In addi­
tion, a traditional syringe is handled with a palm-thumb
grasp, which is not designed for ideal ergonomics or needle
control during the injection. For certain practitioners­
those with small hands-just holding a syringe with a full
cartridge of anesthetic may be difficult.
In 1997 the first computer-controlled local anesthetic Figure 5-15. The Wand has a lightweight handpiece that pro­
vides improved tactile sensation and control.
delivery (C-CLAD) system was introduced into dentistry.
The Wand (Milestone Scientific Inc., Livingston, NJ) was
designedto improve on the ergonomicsand precision of the
dental syringe (Fig. 5-13). This system enabled a dentist or injection experience demonstrated in many clinical studies
hygienist to accurately manipulate needle placement with conducted with these devicesin dentistry.P'" Severalclinical
fingertip accuracy and deliver the local anesthetic with a trials in medicine have demonstrated measurable benefits of
foot-activated control (Fig. 5-14). A lightweight handpiece this technology.F'"
(Fig. 5-15), held in a penlike grasp, provides increased Hochman and colleagueswere the first to demonstrate a
tactile sensation and control compared with the traditional marked reduction in pain perception with injections using
syringe.Availableflow rates of local anesthetic delivery are C-CLADs.11 Fifty blindfolded dentists participated (they
computer controlled and thus remain consistent from one receivedthe injection) in a controlled clinicalstudy compar­
injection to the next. C-CLADsystemsrepresent a significant ingthe standard manual syringewith TheWand/CompuDent
change in the manner in which a local anesthetic injection System for palatal injection. Forty-eight (96%) preferred
is administered. The operator is now able to focus attention injections with the C-CLADs.Overall pain perception was
on needle insertion and positioning, allowingthe motor in reduced two- to threefold when compared with the standard
the device to administer the drug at a preprogrammed manual syringe.
rate of flow.It is likelythat greater ergonomic control cou­ Nicholson and associatesconducted a randomized clini­
pled with fixed flow rates is responsible for the improved cal study using two operators administering four different

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CHAPTER 5 The Syringe 85

A B
Figure 5·16. Anaeject computer-controlled local anesthetic delivery system.

Fukayamaand associatesconducted a controlled clinical


study to evaluate the pain perception of a C-CLADdevice.
Seventeenof20 subjectsreported a slight- or no-pain rating
A on a visual analog scale (VAS)for palatal injections admin­
istered with C-CLADs.Investigators concluded, "The new
systemprovides comfortable anesthesiafor patients and can
be a good alternative for conventional manual syringe
injection."15
1 •.••
At present, three C-CLADs are available in the North
American market: The Wand/CompuDent System, The
Wand/STA System, and the Comfort Control Syringe.
Another system, the Quick.Sleeper,is marketed in Europe.
Similar devices,such as the Anaeject,are marketed in Japan
(Fig.5-16).

The Wand/STA System. The STA-SingleTooth Anesthesia


Figure 5-17. STA (Single Tooth Anesthesia) C-CLAD system.
System(MilestoneScientificInc., Livingston,NJ) represents
a significantadvancein C-CLADtechnology (Fig.5-17).The
STASystemwas introduced in 2007. This third-generation
types of dental injections to compare C-CLADswith the C-CLADinstrument represents a new and meaningful inno­
standard syringe." Mean injection discomfort ratings were vation for subcutaneous injections performed both in den­
found to be consistently lower when C-CLADswere used tistry and in medicine.19 The technological advancement is
compared with the manual syringe. Two thirds of patients related to the development of what is called dynamic
preferred that future dental injections be performed with a pressure-sensing technology (DPS technology)." DPS tech­
C-CLADsystem.Investigatorsin the study increasinglypre­ nology enables the precise monitoring and control of fluid
ferred to perform all injections with C-CLADtechnology. pressure at the needle tip when a subcutaneous injection is
Perry and Loomer presented data from a single-blind performed. Fluid exit-pressure at the needle tip is used to
crossover study comparing C-CLADs with traditional identify a given anatomic location and/or a specific tissue
syringe deliveryof local anesthetic for quadrant scalingand type based on this repeatable finding.21 Exit-pressureinfor­
root planing. Twenty subjects receivedthe anterior middle mation is provided to the clinician on a continuous basis in
superior alveolar nerve block (AMSA)injection (described the form of spoken and/or audible sounds and visual indica­
in Chapter 13).Scoresfor AMSAcomputer-controlled injec­ tors emitted from the STAinstrument, thus providing con­
tion revealed highly significant differences in favor of the tinuous real-time feedback while a dental injection is
computer-controlled device (P <.0001).14 performed (Fig. 5-18,A through C).22

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86 PARTII The Armamentarium

••

Figure 5-18. Dynamic PressureSensing(DPS) on the '·


STA Single Tooth Anesthesia C-CLAD device provides
both visualand audible feedbackregardingplacement of
the needle tip during the periodontal ligament (PDL)
injection. Horizontal color bars indicate pressure at the
tip of the needle.A, Red-pressure is too low.B, Orange
and dark yellow-increasing pressure but not yet ade­

quate. C, Light yellow-correct pressure for PDL injec­
tion. At this point (C) the STAunit will also provide an
audible clue"PDL,PDL,PDL''that the needletip is prop­
erly situated.

The STASystem instrument can perform all traditional considered a "blinded" approach to PDL injection. In con­
injections, as well as several newer dental injection tech­ trast, using the DPS technology of the STASysteminforms
niques as previouslydescribed with The Wand and Compu­ the clinician of the status of needle position based on real­
Dent Systeminstruments. In addition, the STASystemoffer time information. This transforms the PDL injection tech­
a unique approach for performing PDL (intraligamentary) nique into a "guided" technique that can be easily and
injection using DPS technology.22 The instrument has been accurately performed. Additionally,the STAinstrument is
designedto accuratelyidentifythe preciseanatomic location capable of generating precise fluid pressures in ranges that
for the intraligamentary (PDL) injection." The STASystem are much lower in comparison with other injection devices.
audibly and visually "guides" placement of the needle tip This ability to maintain lower pressurespermits the absorp­
into the anatomic entrance of the periodontal ligament tion of greater volumes of anesthetic solution safely and
space through DPS technology.Important to the successof effectivelythrough the intraligamentary tissues-another
the PDL injection is proper needle placement into its the benefit of this technology.24 Allowing a greater volume of
PDL space.Use of a traditional syringe provides little or no anesthetic to be safelyadministered results in a longer dura­
information as to correct needle-tip location, so this can be tion of anesthesia produced by the STA intraligamentary

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CHAPTER 5 The Syringe 87

Figure 5-19. STAWand handpiece is lightweight (lessthan 10 grams) (A) and can easilybe shortened to aid in administration of some
injections (B}, such as the AMSAor other palatal techniques.

injection compared with intraligamentary (PDL) injection


performed using high-pressure syringes and/or other deliv­
ery instruments. 25
Ferrari and coworkers published data on 60 patients
receiving the intraligamentary (PDL) injection; they com­
pared the STASystemversustwo other deliveryinstruments:
a high-pressure mechanicalsyringe (Ligmaject,IMAAssoci­
ates) and a conventional dental syringe.25 Electrical pulp
testing was performed on all teeth at regular intervals to
determine success or failure when these different instru­
ments are used. In addition, patient subjectivepain responses
were recorded post treatment. This study found the STA
Systemto have a successrate of 100%in achieving effective
pulpal anesthesia,as well as more rapid onset of anesthesia.
The PDL injection in this study was performed as a primary
injection for restorativedental care in mandibular teeth. The
study also found subjective pain responses of "minimal or
no pain" observed in all patients receiving PDL injections
with the STASystem.In contrast, PDL injections performed
with the other two systems were found to have generally
higher pain scores throughout testing. Investigators con­ Figure 5-20. The STAWand handpiece is held in an instrument
cludedthat the STAinstrument provided a more predictable, grasp permitting the administrator greater tactile sensitivityduring
more reliable, and more comfortable PDL injection than a the injection.
high-pressure mechanical syringe or a conventional dental
syringe. (Fig. 5-21) that is availablein two forms: one in which the
The STA System has two basic components: the STA handpiece has a preattached needle, and one in which a
Wand handpiece and the STA drive unit. The STAWand needle needs to be attached at the time of treatment. When
handpiece is a single-use (per patient visit) lightweight the STAintraligamentary (PDL) injection is performed, it is
handpiece (weighingless than 10 g) (Fig. 5-19, A and B). It suggestedthat a preattached needle handpiece be used. The
provides excellenttactile control and use of a more desirable STAWand handpiece provides the general benefit of being
ergonomic grasp (Fig.5-20). Clinicianshave reported that a easierand lighter to hold, allowingfor greater accessand ease
C-CLADinstrument, such as the STASystem,is more com­ of use as compared with the conventionalsyringe.Addition­
fortable to use and produces fewermusculoskeletalproblems ally,the STAWand handpiece can be modified to different
over the long term. 26 lengths for greater versatilityof use (see Fig.5-19, B).
STAWand handpieces are availablewith many standard The second component of the STASystem is the drive
dental needle sizes: 30-gauge Yi inch, 27-gauge Yi inch, unit itself.The drive unit integrates two cap holders into the
30-gauge 1 inch, and 27-gauge 1,Xinch needle lengths. The base of the unit, thus allowing single-handed recapping of
STAWand handpiece is a single-use sterilized handpiece the needle from either side of the unit (see Fig. 5-17). New

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88 PARTII The Armamentarium

BOX 5-9 Advantages and Disadvantages of The Wand/


STA System
wflf STA ..._,._ Jllif. Advantages
Dynamic pressure-sensing (DPS) technology provides
continuous real-time feedbackwhen an injection is
performed, resulting in a more predictable injection
site location.
Allowsthe periodontal ligament (PDL) injection to be
used as a predictable primary injection
......· ..a·--- Can be used for all traditional injection techniques
Recommended devicefor newer injection techniques
such as anterior middle superior alveolarnerve
block (AMSA),palatal anterior superior alveolar
nerve block {P-ASA),and STA-intraligamentary
injection
Reducespain-disruptive behavior in children and
adults
Reducesstress for patient
Reducesstress for operator
Figure 5-21. The STA Wand handpiece is presterilized, single­
use and is available in a variety of needle gauge and lengths. Other Disadvantages
Luer-Lok needles can also be sued on this handpiece. Requiresadditional armamentarium
Cost

features not previously availablewith earlier versions of this


C-CLAD device (Wand, CompuDent) include automatic
purging of anesthetic solution that primes the handpiece MIDWEST
C<:ifn1on r Ll"'~'or•. :..-·". J•
before use, automatic plunger retraction after completion of
use, and a multicartridge feature that reduces anesthetic
waste when more than one anesthetic cartridge is used. The
STASystemalso has a Training Mode feature that provides .-
clinicians with spoken instructional guidance on its use, _,,,,......,
thereby minimizing the learning curve when the system is
• •
used for the first time.
Advantagesand disadvantagesof The Wand/STASystem
are listed in Box 5-9.
.,
.•.
•..... •
Comfort Control Syringe. Introduced several years after
The Wand, the Comfort Control Syringe (CCS) System
attempts to improve on the C-CLAD concept. The CCS
Systemis an electronic,preprogrammed deliverydevicethat
provides the operator with the control needed to make the
patient's local anesthetic injection experience as pleasant as
possible (Fig.5-22).As with other C-CLADs,this is achieved
by depositing the local anesthetic more slowlyand consis­ Figure 5-22. Comfort Control Syringe (CCS) body.
tently than is possible manually. The CCS has a two-stage
deliverysystem.Injection begins at an extremelyslowrate to • The front button with the arrow and square controls
avoidthe pain associatedwith rapid anesthetic delivery.After the "Start/Stop" functions by initiating or terminating
10 seconds,the CCS automatically increasesspeed to a pre­ the selectedprogram.
programmed injection rate for the technique selected. Five • The middle button activatesthe ·~piration" function
preprogrammed injection rates are available for specific by slightlyretracting the plunger.
injections: Block, Infiltration, PDL, AMSNpalatal anterior • The rear button initiates "Double Rate"and operates in
superior alveolar nerve block (P-ASA), and Lingual the same manner as the Double Rate button on the
Infiltration. unit. It doubles the preprogrammed injection rate.
The handpiece controls are shown in Figure 5-23. Re-selectingit restores the preprogrammed speed.

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CHAPTER 5 The Syringe 89

of patient discomfort can be significant. The nasopalatine


nerve block, as well as other palatal injections (e.g.,AMSA,27
P-ASA28}, can be administered atraumatically in most
patients. It is reasonableto concludethat any injection tech­
nique that has evena remote possibilityof being uncomfort­
able for the patient can be deliveredmore comfortablyusing
a C-CLADdevice.

CARE AND HANDLING OF SYRINGES


When properly maintained, metal and plastic reusable
syringes are designed to provide long-term service.Follow­
ing is a summary of manufacturers' recommendations con­
cerning care of these syringes:
1. After each use, the syringe should be thoroughly washed
and rinsed so as to be free of any local anesthetic
solution, saliva,or other foreign matter. The syringe
should be autoclavedin the same manner as other
surgical instruments.
2. After everyfive autoclavings,the syringe should be
Figure 5-23. Comfort Control Syringe (CCS) handpiece.
dismantled and all threaded joints and the area where
the piston contacts the thumb ring and the guide
bearing should be lightly lubricated.
3. The harpoon should be cleaned with a brush after
each use.
BOX 5-10 Advantages and Disadvantages of the 4. Although the harpoon is designed for long-term use,
Comfort Control Syringe prolonged use will result in decreasedsharpness and
failure to remain embedded within the stopper of the
Advantages Disadvantages
cartridge. Replacementpistons and harpoons are readily
Familiar"syringe"type of Requiresadditional
availableat low cost.
deliverysystem armamentarium
Easyto see exactlyhow More bulky than other
much local anesthetic computer-controlled PROBLEMS
solution has been local (C-CLAD) Leakage During Injection
dispensed,just as on a manual local anesthesia
When a syringe is reloaded with a second local anesthetic
manual syringe deliverydevices
cartridge and a needle is alreadyin place,care must be taken
Inexpensivedisposables Vibration may bother
to ensure that the needle penetrates the center of the rubber
(=50¢/use) some users
diaphragm. An off-center perforation produces an ovoid
All controls literallyat Cost
puncture of the diaphragm, allowing leakage of the anes­
the fingertips
thetic solution around the outside of the metal needle and
Lesscostlythan other
into the patient's mouth (Fig. 5-24). (For further informa­
C-CLADs
tion, see Chapter 7.)
Allowssdection of various
rates of delivery Broken Cartridge
matched to the user
A badly worn syringe may damage the cartridge, leading to
injection technique
breakage.This also can result from a bent harpoon. A needle
utilized
that is bent at its proximal end (Fig.5-25) may not perforate
C-CLAD,Computer-controlled local anesthetic delivery. the diaphragm on the cartridge. Positive pressure on the
thumb ring increases pressure within the cartridge, which
may cause the cartridge to break.

Standard dental local anesthetic cartridges and dental Bent Harpoon


needles may be used in the CCS. Box 5-10 lists advantages The harpoon must be sharp and straight (Fig.5-26). A bent
and disadvantagesof the CCS. harpoon produces an off-center puncture of the silicone
C-CLADsallowlocalanestheticsto be administered com­ rubber plunger, causing the plunger to rotate as it moves
fortably to the patient in virtually all areas of the oral cavity. down the glass cartridge. This may result in cartridge
This is of greatest importance in the palate, where the level breakage.

www.ShayanNemoodar.com
90 PARTII The Armamentarium

Figure 5-25. Bent needle.A needlebent at the proximalend may


not perforate the cartridge diaphragm. Pressureon the thumb ring
can lead to cartridge breakage.

Figure 5-26. Note the bent harpoon of the syringeon the right.

RECOMMENDATIONS
Figure 5-24. Eccentricperforation. A, Centric perforation of the
diaphragm by a needle prevents leakage during injection. B, Off­ No conclusive evidence indicates that any manufacturer's
center perforation (arrow) permits leakage of anesthetic solution syringe is superior. Therefore the ultimate decision in selec­
into the patient's mouth. tion of a syringe must be left to the discretion of the buyer.
It is recommended, however, that before purchasing any
syringe,the buyer placea full dental cartridge into it and pick
up the syringe as if to use it. It should be noted whether the
fingers (thumb to other fingers) are stretched maximally,
Disengagement of the Harpoon from the because to aspirate with a harpoon-type syringe, one must
Plunger During Aspiration be able to pull the thumb ring back several millimeters. If
Disengagement occurs if the harpoon is dull or if the one is not able to do so, reliable aspiration is not possible.
administrator applies too much pressure to the thumb Although all syringesavailabletoday are of roughlythe same
ring during aspiration. If this happens, the harpoon should dimensions, some variation is noted. Manufacturers market
be cleansed and sharpened or replaced with a new sharp syringeswith smaller thumb rings or shorter pistons. These
harpoon. Disengagement is most likely to occur when a modifications make aspiration easier to accomplish for
30-gauge dental needle is being used because significant persons with smaller hands.
resistance is produced within the needle lumen as aspira­ Followingare additional recommendations:
tion is attempted A very gentle backward motion of the 1. A safetysyringe,minimizing the risk of accidental
plunger is all that is necessary for successful aspiration. needle-stick injury, is recommended for use during all
Forceful action is not necessary. (See the discussion in local anesthetic injections.
Chapter 11.) 2. A self-aspiratingsyringe is recommended for
practitioners with small hands.
Surface Deposits 3. Any syringe system used must be capable of aspiration.
An accumulation of debris, saliva,and disinfectant solution Nonaspirating syringesshould never be used for local
interferes with syringe function and appearance. Deposits, anesthetic injections.
which can resemble rust, may be removed with a thorough 4. All reusable syringesmust be capable of being sterilized
scrubbing. illtrasonic cleaningwill not harm syringes. 5. Nonreusable syringesmust be disposed of properly.

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CHAPTER 5 The Syringe 91

new injection system: The Wand, Quint Int 34:737-741,


References 2003.
1. Council on Dental Materials and Devices: New American 16. Tan PY,Vukasin P, Chin ID, et al: The Wand local anesthetic
National Standards Institute/American Dental Association deliverysystem,Dis Colon Rectum 44:686--689,2001.
specificationno. 34 for dental aspirating syringes,J Am Dent 17. Landsman A, DeFronzo D, Hedman J, McDonald J: A new
Assoc97:236-238, 1978. systemfor decreasingthe levelof injection pain associatedwith
2. Council on Dental Materials, Instruments, and Equipment: local anesthesia of a toe, (abstract). Annual Meeting of the
Addendum to American National Standards Institute/ American Academyof Podiatric Medicine 2001.
American Dental Association specification no. 34 for dental 18. Friedman MJ, Hochman MN: 21st century computerized
aspirating syringes,J Am Dent Assoc 104:69-70,1982. injection for local pain control, Compend Contin Educ Dent
3. Bartlett SZ: Clinical observations on the effects of injections 18:995-1003,1997.
of local anesthetic preceded by aspiration, Oral Surg 33:520, 19. KudoM, Ohke H, KatagiriK,et al:The shape oflocal anesthetic
1972. injection syringeswith less discomfort and anxiety: evaluation
4. Malamed SF: Handbook of local anesthesia, St Louis, 1980, of discomfort and anxiety caused by various types of local
Mosby. anesthetic injection syringesin high leveltrait-anxiety people,
5. Meechan JG, Blair GS,McCabeJF: Localanaesthesiain dental J Jpn Dent Soc Anesthesiol29:173-178,2001.
practice. II. A laboratory investigation of a self-aspirating 20. Hochman MN, Friedman MJ: In vitro study of needle
system,Br Dent J 159:109-113,1985. deflection: a linear insertion technique versus a bi-directional
6. Meechan JG:A comparison of three different automatic aspi­ rotation insertion technique, Quint Int 31:737-743,2000.
rating dental cartridge syringes,J Dent 16:40--43,1988. 21. Hochman MN, Friedman MJ:An in vitro study of needle force
7. Peterson JK: Efficacyof a self-aspirating syringe, Int J Oral penetration comparing a standard linear insertion to the new
MaxillofacSurg 16:241-244,1987. bidirectional rotation insertion technique, Quint Int 32:789-
8. FiggeFHJ, Scherer RP: Anatomical studies on jet penetration 796, 2001.
of human skin for subcutaneous medication without the use 22. PashleyEL,Nelson R, PashleyDH: Pressurescreated by dental
of needles,Anat Rec 97:335,1947 (abstract). injections, J Dent Res 60:1742-1748,1981.
9. Margetis PM, Quarantillo EP,Lindberg RB:Jet injection local 23. Fuhs QM,WalkerWA,Gouigh RW,et al: The periodontal liga­
anesthesia in dentistry: a report of 66 cases,US Armed Forces ment injection: histological effects on the periodontium in
Med J 9:625--634,1958. dogs, J Endodont 9:411-415, 1983.
10. Hoffmann-Axthelm W: History of dentistry, Chicago, 1981, 24. Galili D, Kaufman E, Garfunkel AA, et al: Intraligamentary
Quintessence,p 339. anesthesia: a histological study, Int J Oral Surg 12:511-516,
11. Hochman MN, ChiarelloD,Hochman CB,et al:Computerized 1984.
local anesthesia delivery vs. traditional syringe technique, 25. Albers DD, Ellinger RF: Histologic effects of high- pressure
NY State Dent J 63:24-29, 1997. intraligamental injections on the periodontal ligament, Quint
12. Gibson RS,Allen K, Hutfless S, et al: The Wand vs. traditional Int 19:361-363,1988.
injection: a comparison of pain related behaviors,Pediatr Dent 26. Froum SJ, Tarnow D, Caiazzo A, et al: Histologic response
22:458--462,2000. to intraligament injections using a computerized local anes­
13. Nicholson JW, Berry TG, Summitt JB, et al: Pain perception thetic deliverysystem:a pilot study in Mini-Swine,J Periodont
and utility: a comparison of the syringeand computerizedlocal 71:1453-1459,2000.
injection techniques, Gen Dent 49:167-172,2001. 27. Friedman MJ, Hochman MN: The AMSA injection: a new
14. Perry DA, Loomer PM: Maximizing pain control: the AMSA conceptfor localanesthesiaof maxillaryteeth usinga computer­
injection can provide anesthesia with few injections and less controlled injection system,Quint Int 29:297-303, 1998.
pain, Dimensions Dent Hyg 1:28-33,2003. 28. Friedman MJ, Hochman MN: P-ASAblock injection: a new
15. FukayamaH, YoshikawaF,KohaseH, et al: Efficacyof anterior palatal technique to anesthetize maxillary anterior teeth,
and middle superior alveolar (AMSA) anesthesia using a J Esthet Dent 11:23-71, 1999.

www.ShayanNemoodar.com
I

The Needle
' I •I

Fig.6-1). Twofactorsto be consideredabout this component


TYPES
of the needle are the diameter of its lumen (e.g.,the needle
The needle is the vehiclethat permits local anesthetic solu­ gauge) and the length of the shaft from point to hub.
tion to travel from the dental cartridge into the tissues sur­ The hub is a plastic or metal piece through which the
rounding the needle tip. Most needles used in dentistry are needle attaches to the syringe.The interior surfaceof metal­
stainless steel and disposable. Needles manufactured for hubbed needles is prethreaded, as are most but not all
dental intraoral injections are presterilized and disposable. plastic-hubbed needles.
Reusableneedles should not be used for injections. The cartridge-penetrating end of the dental needle extends
Becausethe needle represents the most dangerous com­ through the needle adaptor and perforates the diaphragm of
ponent of the armamentarium, the one most likely to the local anesthetic cartridge. Its blunt end rests within the
produce injury to patient or doctor, safety needles are being cartridge.
developed.1•2Although these needles are not yet used to any When needles are selected for use in various injection
appreciable degree in dentistry in the United States, it is techniques, two factors that must be considered are gauge
likelythat at some point in the not too distant future their and length.
use will become commonplace, if not mandatory.
GAUGE
ANATOMY OF A NEEDLE Gauge refers to the diameter of the lumen of the needle:the
The needle is composed of a single piece of tubular metal smaller the number, the greater the diameter of the lumen.
around which is placed a plastic or metal syringe adaptor A 30-gauge needle has a smaller internal diameter than a
and the needle hub (Fig.6-1). 25-gauge needle. In the United States, needles are color­
All needles have the followingcomponents in common: coded by gauge (Fig.6-5).
the bevel, the shaft, the hub, and the cartridge-penetrating There is a growing trend toward the use of smaller­
end (Fig.6-2). diameter (higher-number gauge) needles, based on the
The bevel definesthe point or tip of the needle.Bevelsare assumption that they are less traumatic to the patient than
described by manufacturers as long, medium, and short. needles with larger diameters (Table 6-2). This assumption
Severalauthors have confirmed that the greater the angle of is unwarranted.7 Hamburg8demonstrated as far back as 1972
the bevelwith the long axis of the needle,the greater will be that patients cannot differentiate among 23-, 25-, 27-, and
the degree of deflection as the needle passesthrough hydro­ 30-gauge needles. Others have confirmed this finding.v" A
colloid (or the soft tissues of the mouth) (Fig. 6-3).3-6 A clinical experiment demonstrates this point:
needle whose point is centered on the long axis (e.g., the 1. Three needles-25-, 27-, and 30-gauge-are selected.
Huber point, the Truject needle; Fig.6-4, A) will deflectto a 2. The buccal mucosa over the maxillary anterior teeth
lesser extent than a beveled-point needle, whose point is should be dried.
eccentric (Fig.6-4, B) (Table6-1). 3. No topical anesthetic should be used.
Severalmanufacturers of dental needleshaveplaced indi­ 4. The mucosa should be taut.
cators on the plastic or metal hub to help orient the doctor 5. The mucosa should be gently penetrated (about 2 to
to the position of the bevel during needle insertion and 3 mm) with each of the three needles without revealing
injection of the drug. to the patient which needle is being used. A different
The shaft of the needle is one long piece of tubular metal site should be selectedfor each penetration.
running from the tip of the needle through the hub, and 6. Question the patient about his or her "feelings":Which
continuing to the piece that penetrates the cartridge (see one was felt the most? Which one the least?
92

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CHAPTER 6 The Needle 93

Figure 6-1. Metal disposable needle, dissembled.

Figure 6-3. Radiograph demonstrating varying degrees of


needle deflection with different gauges (left to right, 30-, 27-,
and 25-). (From Robison SF,MayhewRB,Cowan RD,et al: Com­
Cartridge­ parative study of deflection characteristicsand fragilityof 25-, 27-,
Syringe
Bevel Shaft Hub
adaptor
penetratlon and 30-gauge short dental needles, J Am Dent Assoc 109:920-924,
end 1984.)

\ I
lumen. Foldesand McNall11 reported the followingfindings
based on an unpublished study by Monheim:
Figure 6-2. Components of dental local anesthetic needle. Long
1. One hundred percent positive aspirations were achieved
needle (top);short needle (bottom).
from blood vesselswith 25-gaugeneedles.
2. Eighty-sevenpercent positive aspirations were achieved
from blood vesselswith 27-gaugeneedles.
In literally hundreds of clinical demonstrations, no 3. Twopercent positive aspirations were achievedfrom
patient was able to correctly determine the gauge of each blood vesselswith 30-gaugeneedles.
needle.The usual response has been that he or she could not Trapp and Davies15 reported that in vivo human blood
discern any difference. maybe aspirated through 23-,25-,27-,and 30-gaugeneedles
Larger-gaugeneedles (e.g.,25-gauge,27-gauge)have dis­ without a clinically significant difference in resistance to
tinct advantagesover smallerones (30-gauge)(Box6-1): less flow.
deflection occurs as the needle passes through tissues (see Despite this ambiguity concerning ability to aspirate
Table6-1 and Fig.6-3). This leads to greater accuracy during blood through needles of various gauges,the use of larger
needle insertion (it goesin a straighter line) and, it is hoped, needles (e.g., 25-gauge,27-gauge) is recommended for any
to increased successrates, especiallyfor techniques in which injection technique used in a highly vascular area, or when
the depth of soft tissue penetrated is significant(e.g.,inferior needle deflection through soft tissue would be a factor.
alveolar,Gow-Gatesmandibular, Akinosi-Vaziranimandib­ Although blood may be aspirated through all 23- through
ular, anterior superior alveolar [ASA;infraorbital] nerve 30-gauge needles, resistance to aspiration is greater when
blocks).Needle breakage, although rare today with the use of smaller-gauge needles are used, increasing the likelihood
disposable needles, is even less likely to occur with a larger that the metal harpoon will become dislodged from the
needle. Numerous authors'':" have demonstrated that aspi­ rubber plunger during aspiration, making the aspiration
ration of blood is easier and more reliable through a larger attempt futile.

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94 PART II The Armamentarium

Heel area shielded by point

------
No deflection on penetration
Inside diameter 0.008 inch; same as 27-gauge
A Outside diameter 0.014 inch

------
Angle of deflection on penetration
Inside diameter 0.008 inch
Outside diameter O.Q16 inch
B 27-gauge needle with standard point
Figure 6-4. A, The tip of a nondefl.ectingneedle is located in the center of the shaft,thereby minimizing deflectionas the needle penetrates
soft tissues.B, Conventional dental needle.The needle tip lies at the loweredgeof the needle shaft,thereby producing deflectionas the needle
passesthrough soft tissue.

TABLE 6-1
Deflection of Needles Inserted in Hydrocolloid Tubes
to Their Hubs
Maximum Tip
Length Deflection
(mm, Tip to Hub) (mm,± SD)
25-Gaugelong 35 7.1±0.81*
(conventional)
27-Gaugelong 36 8.4 ± 1.2*
(conventional)
27-Gauge short 26 4.6±0.97t
(conventional)
28-Gaugelong 31 1.1±0.82
(nondeflecting)
28-Gauge short 22 0.8 ± 0.91 Figure 6-5. Color-coding by needle gauge: 25-gauge, red;
(nondeflecting) 27-gauge,yellow;30-gauge,blue.
Data modified from JeskeAH, Boshart BF:Deflection of conventional
versus non-deflecting dental needles in vitro, Anesth Prog 32:62-64,1985.
*A statisticallysignificant differencefrom the nondeflecting long needle
(P < .01); n = 10 needles in each group.
tA statisticallysignificant differencefrom the nondeflecting short needle TABLE 6-2
(P < .01); n = 10 needles in each group. Needle Purchases, U.S. Dentistry, 2006
DATA PROVIDED BY
Sullivan-Schein Septodont
Gauge Length Inc. (2006) Inc. (2006)
BOX 6-1 Advantages of Larger-Gauge Needles Over 25 Short <1% 1% 0.6% 3%
Smaller-Gauge Needles Long 1% 2.3%
27 Short 10% 42% 13% 38%
1. Lessdeflection,as needle advancesthrough tissues
Long 32% 25%
2. Greater accuracyof injection
30 Short 50% 56% 51% 59%
3. Lesschance of needle breakage Extra short 6% 8%
4. Easier aspiration
5. No perceptual differencein patient comfort From Malamed SF,Reed KL,Poorsattar S:Needle breakage:incidence and
prevention, Dent Clin North Am 54:745-756,2010.

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CHAPTER 6 The Needle 95

deflectionoccurring as the needle passesthrough soft tissues


TABLE 6-3
actually results in an increased rate of successfulanesthesia
Specifications for Needle Gauges*
compared with that observed with standard needles. Over
Gauge Outer Diameter, mm Inner Diameter, mm years of use, dentists become accustomed to the deflecting
7 4.57 3.81 needles they use and gradually modify their injection tech­
8 4.19 3.43 niques to accommodatethis deflection (they"learn"to make
10 3.40 2.69 the injections work even with deflection). Changing to a
11 3.05 2.39 nondeflecting needle might initially lead to lower success
12 2.77 2.16 rates.
13 2.41 1.80
14 2.11 1.60 Minimizing Needle Deflection: Bi-Rotational
15 1.83 1.32 Insertion Technique (BRIT)
16 1.65 1.19
17 1.50 1.04
A new approach to reducing needle deflection has been
18 1.27 0.84 described.17Rotational insertion (described as bi-rotational
19 1.07 0.69 insertion technique [BRIT]),a technique in which the oper­
20 0.91 0.58 ator rotates the handpiece or needle in a back-and-forth
21 0.81 0.51 rotational movement while advancing the needle through
22 0.71 0.41 soft tissue, is similar to techniques used for acupuncture or
23 0.64 0.33 endodontic instrumentation. Hochman and Friedman dem­
25 0.51 0.25 onstrated that needle deflection could be virtually elimi­
26 0.46 0.25 nated by using a rotational insertion technique during needle
27 0.41 0.20 advancement.17An in-vitro study of 60 needle insertions
30 0.31 0.15
into a tissue-like medium was performed with needles of
*Dental needle gauges highlighted. three differentgaugesto compare rotational insertion versus
the traditional linear nonrotating insertion technique. Inves­
tigators demonstrated that deflectionalbending of a needle
Industry standards for needle gauge have been in place could be minimized or eliminated, regardless of the length
for years (Table 6-3); however,variations in internal diam­ or gauge of a needle, as long as the insertion was performed
eter do exist between needle manufacturers. Larger-gauge using the bi-rotational insertion technique.
needles (e.g.,25-gauge,27-gauge) should be used when the Deflectionof a needle is a consequenceof resultant forces
risk of positive aspiration is increased, as during an inferior acting on the needle bevel during tissue penetration and
alveolar,posterior superior alveolar, or mental or incisive advancement.An eccentricpointed beveledneedle generates
nerve block. severaldifferent forces that act on it during insertion when
The most commonly used (e.g., most often purchased) a nonrotating linear insertion technique is used. A linear
needles in dentistry are the 30-gaugeshort and the 27-gauge insertion technique is the conventionaltechnique used with
long.16The 25-gauge (long or short) remains the preferred the traditional dental syringe,which is typicallyheld with a
needle for all injections presenting a high risk of positive palm-thumb grasp (Fig.6-6). During this type of insertion,
aspiration. The 27-gaugecan be used for all other injection a force perpendicular to the forward directional movement
techniques, provided the aspiration percentage is low and (vector) acts on the surface of the beveled needle, causing
tissue penetration depth is not great (increased deflection the needle to bend (or deflect) in a direction opposite to
with this thinner needle).The 30-gaugeneedle is not specifi­
cally recommended for any injection, although it may be
used in instances of localizedinfiltration, as when hemosta­
sis is attained during periodontal therapy.
Deflectionof the needle is a consideration when a needle
must penetrate a greater thickness of soft tissue. On the
standard dental needle (see Fig.6-4, B), the tip of the point
is located eccentrically.As the needle shaft penetrates soft
tissue, the point of the needle is deflected by the tissue
through which it passes.The greater the angle of the bevel,
the greater is the degree of needle deflection. Everydecade
or so, a needle is introduced on which the tip of the point is
located in the center of the lumen, thereby minimizing
deflection as the needle passes through soft tissue (see Fig.
6-4,A). Jeskeand Boshart4 demonstrated the effectivenessof
this "nondeflecting"needle (seeTable6-1). However,it needs
to be demonstrated clinicallythat a lesser degree of needle Figure 6-6. Traditional syringeheld in palm-thumb grasp.

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96 PART II The Armamentarium

which the bevel faces (e.g., if the bevel faces "up," the advanc­ syringerequires a palm-thumb grasp (seeFig.6-6) that does
ing movement causes a beveled needle to deflect "down­ not permit such a technique. A computer-controlled local
ward"). The longer the needle length, the more exaggerated anesthetic delivery (C-CLAD) device such as The Wand/
the bending or deflection becomes as a result of the greater CompuDent/STA (Milestone ScientificInc., Livingston,NJ;
distance traveled along the deflecting path. The smaller the discussed in Chapter 5) employs a lightweight handpiece
diameter of the needle, the more exaggerated the bending or that is held with a "penlike" or "dart" grasp that is easily
deflection, because a smaller-gauge needle is less capable of rotated
resisting the deflection or bending force on the surface of the A subsequent study by the same authors demonstrated
beveled needle tip. that the BRIToffersthe added benefit of reducing the force
When the BRIT is used during needle insertion, the per­ necessaryfor needle penetration and advancement through
pendicular force that causes deflection is eliminated or "neu­ tissues.18 This is explained as follows.With rotational inser­
tralized" from the constant changing of bevel orientation as tion, all resultant forcesare directed toward the forward path
it is rotated (Fig. 6-7).17 This allows eccentricallybeveled of insertion because the deflecting or bending forces have
needles to travel in a straight path. The traditional handheld been eliminated from the rotational insertion technique, as
described earlier. This allows forward movement of the
needle to occur more efficientlyand with lesseffort (e.g.,less
force). In addition, rotation of the beveledneedle allowsthe
sharp cutting edge to contact the full circumference of the
tissue surface, contributing to the reduction in force that is
necessaryduring penetration and advancement. This is not
unlike the rotational effectthat a surgicaldrill bit has as it is
boring through tissue or bone.
The BRIT,or bi-rotational insertion technique has been
demonstrated to improve injection techniques because
the deflection of a standard needle during insertion is
minimized.19

LENGTH
Dental needles are availablein three lengths:long, short and
ultrashort. IBtrashort needles are availableonly as 30-gauge
needles.Despitethe claimfor uniformity oflength by manu­
facturers, significant differencesare found (Table6-4).
The length of a short needle is between 20 and 25 mm
(measured hub to tip) with a standard of about 20 mm, and
is 30 to 35 mm for the long dental needle, with a standard
of about 32 mm (Fig.6-8).
Needlesshould not be inserted into tissues all the wayto
their hubs unless this is absolutelynecessaryfor the success
of the injection. This statement has appeared in "standard"
local anesthesia textbooks since the early to mid 1900s.20-24
One reason for this precaution is needle breakage, which,
Figure 6-7. BRIT(bi-rotationalinsertiontechnique). although rare, does occur.The weakestportion of the needle

TABLE 6-4
Needle Lengths*
25-Gauge 25-Gauge 27-Gauge 27-Gauge 30-Gauge 30-Gauge 30-Gauge
Manufacturer Long Short Long Short Long Short Ultrashort
Industrystandard 32 20 32 20
ManufacturerA 30 30 21 25 21
ManufacturerB 32± 1.5 22± 1.5 32± 1.5 22± 1.5 21±1.5 12 ± 1.0
ManufacturerC 32 21 25 21
ManufacturerD 35 35 25 25 10
ManufacturerE 32 21 19
*Allmeasurements
obtaineddirectly
fromneedlemanufacturers.

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CHAPTER6 The Needle 97

~;::iii: i:1::::mii: ·:;:::·~


B

Figure 6-8. A. Longdental needle:length approximately32 mm.


B, Short dental needle: length approximately20 mm.

(the most rigid, the part receivingthe greatest stress during


needle advancement through tissues) is at the hub, which is
where needle breakage happens. When a needle that is
inserted into the soft tissues to its hub breaks, the elastic
properties of the tissues permit them to rebound and cover
(bury) the needle remnant entirely.Retrievalis usually dif­
ficult (as discussed in Chapter 17). If even a small portion Figure 6-9. A. Container for disposal of discarded local anes­
(5 mm or more) of the broken needle shaft remains visible thetic cartridges. B, "Sharps" container for disposal of contami­
within the oral cavity,it can usuallybe retrieved easilywith nated needles.
a hemostat or pickup forceps.
A long needle is preferred for all injection techniques for
which penetration of significant thicknesses of soft tissue patient's mouth. This minimizes the risk of potential
(e.g.,inferior alveolar,Gow-Gatesmandibular,Akinosiman­ injury to the patient and the administrator.
dibular,infraorbital, maxillary [V2] nerveblocks) is required. 5. Needlesmust be properly disposed of after use to
Short needles may be used for any injection in any patient prevent possible injury or reuse by unauthorized
who does not require penetration of significant depths of individuals. Needlescan be destroyed in any of the
soft tissue (e.g., closeto or beyond 20 mm). followingways:
a. Contaminated needles (as well as all other items
contaminated with blood or saliva,such as
CARE AND HANDLING OF NEEDLES cartridges) should be disposed of in special
Needlesavailableto the dental professiontoday are presteril­ "contaminated" or "sharps" containers (Fig.6-9).
ized and disposable. With proper care and handling, they b. Proper use of a self-sheathing ("safety"needle)
should not be the cause of significantdifficulties. needle or syringe unit (as discussed in Chapter 5)
1. Needlesmust never be used on more than one patient. minimizes risk of accidental needle-stick.
2. Needles should be changed after several (three or four) c. When needles are to be reused for subsequent
tissue penetrations in the same patient. injections (a practice unique to the dental profession
a. After three or four insertions, stainlesssteel vs. medicine or other health care professions,where
disposable needles become dulled. Tissue penetration second injections are rarely administered), recapping
becomes increasinglytraumatic with each insertion, is accomplishedusing the "scoop"technique or a
producing pain on insertion and sorenesswhen needle holder (Fig.6-10).
sensation returns after the procedure. d. Contaminated needles should never be discarded
3. Needles should be coveredwith a protective sheath into open trash containers.
when not being used to prevent accidental needle-stick In summary, in actual fact, only one local anesthetic
with a contaminated needle. (Seethe discussion in needle is necessary in the dental office,the 25-gauge long,
Chapter 9.) which can be used for all anesthetic techniques discussedin
4. Attention should alwaysbe paid to the position of the this text. It provides a rigidity that is not available with
uncovered needle tip, whether inside or outside the higher-gauge (smaller-diameter) needles and is necessaryin

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98 PARTII The Armamentarium

A B
Figure 6-10. A, "Scoop"technique for recapping contaminated local anesthetic needle. B, Plastic needle cap holder.

the periodontal ligament (PDL) and for intraseptal injec­


tions; it deflectsto a lesser degree than smaller needles and
seemingly provides easier and more reliable aspiration.
Becausepatient sensitivityis not increasedwith the 25-gauge
long needle, its value is increased still further. In reality,
however,it is practicalto havea secondneedle available-the
25- or 27-gaugeshort needle-for use in injections in which
the thickness of soft tissue to be penetrated is less than
20 mm, and where the risk of positiveaspiration is minimal,
as well as in areas of the oral cavitywhere stabilization of a
long needle might prove difficult (e.g., maxillary anterior
teeth, the palate).

PROBLEMS WITH NEEDLES


Pain on Insertion
Use of a dull needle can lead to pain on initial penetration
of the mucosa. This pain may be prevented by using sharp,
new, disposable needles and applying a topical anesthetic at Figure 6-11. Retained broken needle after inferior alveolar
the penetration site. The needle should be changed after nerve block (arrow).
three or four penetrations of mucosa if multiple insertions
are necessary.
teeth (intrapulpal), or with injection into bone distal to a
Breakage second molar (intraosseous), in which the injection site is
Bendingweakensneedles,making them more likelyto break not accessiblewith a straight needle. In these cases,bending
on subsequent contact with hard tissues such as bone. of the needle is essentialto success.Becausethe needle does
Needlesshould not be bent if they are to be inserted into soft not enter into soft tissue farther than 2 to 4 mm (PDL), or
tissue to a depth greater than 5 mm. No injection technique at all (intrapulpal), there is little danger of the needle being
used in dentistry (in which the needle enters into soft nonretrievable in the unlikelyevent that it breaks (Figs.6-11
tissue) requires a needle to be bent for successof the injec­ and 6-12).
tion. Most often, needles are bent by doctors administering No attempt should be made to change the direction of a
an inferior alveolarnerve block (IANB),a posterior superior needle when it is embedded in tissue. If the direction of a
alveolar (PSA) nerve block, an intrapulpal injection, an needle must be changed, the needle should first be with­
injection into the PDL,or an intraosseous injection.The two drawn almost completelyfrom the tissue and then its direc­
nerve blocks mentioned (IANB,PSA) can be easilyadmin­ tion altered.
istered successfullywith a straight (unbent) needle (see No attempts should be made to force a needle against
Chapters 13 and 14). The PDL and intrapulpal injections resistance (needles are not designed to penetrate bone).
usually can be administered without bending the needle; Smaller (30- and 27-gauge) needles are more likelyto break
however,occasionsarise, such as at the distal root of a man­ than larger (25-gauge) needles. Of 105 broken needle cases
dibular second molar (PDL), with root canals in posterior this author has examined, 100involveda 30-gaugeshort or

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CHAPTER6 The Needle 99

ultrashort needle (95.23%). The remaining five needles were doubt about the presence of barbs, change the needle
27-gauge short," between insertions.
Needles recommended for specific injection techniques
are presented in the following "Recommendations" section. Injury to the Patient or Administrator
Penetration of, with resultant injury to, areas of the body
Pain on Withdrawal with the needle can occur unintentionally.A major cause is
Pain on withdrawal of the needle from tissue can be inattention by the administrator, although sudden unex­
produced by "fishhook" barbs on the tip. Fishhook barbs pected movement by the patient is also a frequent cause.The
may be produced during the manufacturing process, but needle should remain capped until it is to be used and should
it is much more likely that they will develop when the be made safe(sheathed or recapped) immediatelyafterwith­
needle tip forcefullycontacts a hard surface, such as bone. drawal from the mouth.
A needle should never be forced against resistance. If in
RECOMMENDATIONS
1. Sterile disposableneedles should be used.
2. If multiple injections are to be administered, needles
should be changed after three or four insertions in a
single patient.
3. Needlesmust never be used on more than one patient.
4. Needlesshould not be inserted into tissue to their hub
unless this is absolutelynecessaryfor successof the
injection.
5. The direction of a needle should not be changed while
it is still in tissue.
6. A needle should never be forced against resistance.
7. Needlesshould remain capped until used and should be
made safe immediatelywhen withdrawn.
8. Needlesshould be discarded and destroyed after use to
prevent injury or reuse by unauthorized persons.
9. The injection techniques presented in Table6-5 are
Figure 6-12. Remainder of retained local anesthetic needle listed with their recommended needles (for the adult of
shown in Figure 6-11. averagesize).

TABLE 6-5
Recommended Needles for Injection Techniques
Technique Needle Gauge Needle Length
Supraperiosteal (infiltration) 27 Short
Posterior superior alveolarnerve block 2'r Short*
Middle superior alveolarnerve block 27 Short
Anterior middle superior alveolar (AMSA)nerve block 27 Short
Palatal approach anterior superior alveolarnerve block (P-ASA) so' Short
Buccal (long) nerve block 27* Short:j:
Infiltration for hemostasis 27 Short
Periodontal ligament injection (PDL or intraligamentary [ILI]) 27 Short
Intraseptal injection 27 Short
Intraosseous injection 27 Short
Intrapulpal injection 27 Short
Anterior superior alveolarnerve block ("infraorbital") Long
Maxillary (V2) nerve block Long
Inferior alveolar ("mandibular") nerve block Long
Gow-Gatesmandibular nerve block Long
Vazirani-Akinosimandibular nerve block Long
*In earlier editions of this book, the 25-gaugelong needle was recommended. As a means of minimizing the risk of hematoma after the posterior superior
alveolarinjection, a short needle is now recommended. If available,a 25-gaugeshort needle should be used; where this is not available,the 27-gaugeshort
needle is recommended. (SeeChapter 13 for additional discussion.)
"The authors of the P-ASApaper recommend use of a 30-gaugeultrashort needle.1'-"
*Inmost clinicalsituations, the 25-gaugelong needle, used for the inferior alveolarnerve block (IANB),is used for the buccal nerve block, which is
administered immediately after the IANB.

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100 PARTII The Armamentarium

12. Harris S:Aspirations before injection of dental local anesthet­


References ics, J Oral Surg 25:299-303, 1957.
1. Cuny EJ,FredekindR,BudenzAW:Safetyneedles:new require­ 13. Kramer H, Mitton V: Dental emergencies,Dent Clin North Am
ments of the Occupational Safetyand Health Admllristration 17:443-460,1973.
bloodborne pathogens rule, J Calif Dent Assoc 27:525-530, 14. McClure DB: Local anesthesia for the preschool child, J Dent
1999. Child 35:441-448, 1968.
2. Cuny E, Fredekind RE, Budenz AW: Dental sefety needles 15. Trapp LD,DaviesRO:Aspiration as a function of hypodermic
"effectiveness":results of a one-year evaluation, J Am Dent needle internal diameter in the in-vivo human upper limb,
Assoc 131:1143--1148,2000. Anesth Prog 27:49--51,1980.
3. Aldous JA:Needle deflection:a factor in the admllristration of 16. Malamed SF: Personal communications, Newark, Del, April
local anesthetics,J Am Dent Assoc77:602--604,1968. 2006,Septodont Inc.
4. Jeske AH, Boshart BF: Deflection of conventional versus 17. Hochman MN, Friedman MJ: In vitro study of needle deflec­
non-deflecting dental needles in vitro, Anesth Prog 32:62--64, tion: a linear insertion technique versus a bi-directional rota­
1985. tion insertion technique, Quint Int 31:737-743,2000.
5. Robison SF,MayhewRB,Cowan RD,et al: Comparative study 18. Hochman MN, Friedman MJ:An in vitro study of needle force
of deflection characteristics and fragility of 25-, 27-, and penetration comparing a standard linear insertion to the new
30-gaugeshort dental needles, J Am Dent Assoc 109:920-924, bidirectional rotation insertion technique, Quint Int 32:789-
1984. 796, 2001.
6. Delgado-Molina E, Tamarit-Borras M, Berini-AytesL, et al: 19. AboushalaA, KugelG, Efthimiadis N, Krochak M: Efficacyof
Comparativestudy of two needle models in terms of deflection a computer-controlled injection system of local anesthesia in
during inferior alveolarnerve block, Med Oral Patol Oral Cir vivo, IADRAnnual Meeting, 2000,Abstract 2775.
Bucal 14:440-444,2009. 20. Cook-Waite Laboratories Inc.: Manual of local anesthesia in
7. JeskeAH, Blanton PL: Misconceptions involving dental local general dentistry, New York, 1936, Rensselaer & Springville,
anesthesia. Part 2. Pharmacology, Tex Dent J 119:310-314, p 38.
2002. 21. Local anesthesia and pain control in dental practice, St Louis,
8. Hamburg HL: Preliminary study of patient reaction to needle 1957,CV Mosby,p 184.
gauge,NY State Dent J 38:425-426, 1972. 22. Allen GD: Dental anesthesiaand analgesia(local and general),
9. Farsakian LR, Weine FS: The significanceof needle gauge in ed 2, Baltimore,Md, 1979,Williams & Wilkins,p 133.
dental injections, Compendium 12:264--268,1991. 23. YagielaJA, Jastack JT: Regional anesthesia of the oral cavity,
10. Flanagan T, Wahl Ml, Schmitt MM, et al: Size doesn't St Louis, 1981,CV Mosby,p 105.
matter: needle gaugeand injection pain, Gen Dent 55:216-217, 24. Malamed SF:Needles.In Handbook of local anesthesia, ed 5,
2007. St Louis,2004,CV Mosby,p 103.
11. Foldes FF, McNall PG: Toxicity of local anesthetics in man, 25. MalamedSF,ReedKL,Poorsattar S:Needlebreakage:incidence
Dent Clin North Am 5:257-258, 1961. and prevention, Dent Clin North Am 54:745-756,2010.

www.ShayanNemoodar.com
The Cartridge

The dental cartridge is a glass cylinder containing the local 3. Aluminum cap
anesthetic drug, among other ingredients. In the United 4. Diaphragm
States and in many other countries, the glass cylinder itself The stopper (plunger, bung) is located at the end of the
can hold 2 mL of solution; however,as prepared today, the cartridge that receivesthe harpoon of the aspirating syringe.
dental cartridge contains approximately 1.8 mL of local The harpoon is embedded into the silicone (non-latex­
anesthetic solution. Localanesthetic products manufactured containing) rubber plunger with gentle finger pressure
by Septodont (Lancaster, PA) list their volume as 1.7 mL applied to the thumb ring of the syringe.The plunger occu­
(although in actuality they contain approximately 1.76mL pies a little less than 0.2 mL of the volume of the entire
of local anesthetic solution). In other countries, notably the cartridge.Until recently,the stopper was sealedwith paraffin
United Kingdom and Australia,the prefilleddental cartridge (wax) to produce an airtight seal against the glass walls of
contains approximately 2.2 mL of local anesthetic solution; the cartridge. Glycerin was added in channels around the
some countries including France and Japan have 1-mL stopper as a lubricant, permitting it to traverse the glass
dental cartridges (Fig.7-1). cylinder more easily.Today,most local anesthetic manufac­
The dental cartridge is, by common usage,referred to by turers treat the stopper with silicone, eliminating both the
dental professionalsas a carpule. The term carpule is actually paraffin and the glycerin."Stickystoppers" (stoppers that do
a registeredtrade name for the dental cartridge prepared by not move smoothly down the glasscartridge) are infrequent
Cook-WaiteLaboratories,which introduced it into dentistry today. Recent years have seen a move toward the use of a
in 1920. uniform black rubber stopper in all local anesthetic drug
In recent years, local anesthetic manufacturers in some combinations.Virtuallygone are the color-codedred, green,
countries (but not as of yet in North America) have intro­ and blue stoppers that aided in identification of the drug.
duced a local anesthetic cartridge composed of plastic.' When black stoppers are used, a color-codingband, required
Plastic cartridges have several negative features, primarily by the American Dental Association (ADA)as of June 2003
leakage of solution during injection, the requirement for for products to receivethe ADASeal of Approval, is found
considerable force to be applied to the plunger of the around the glasscartridge (Table7-1).
syringe (e.g., periodontal ligament [PDL], nasopalatine),1 In an intact dental cartridge (Fig. 7-3), the stopper is
and the fact that the plunger does not "glide" down the slightlyindented from the lip of the glasscylinder.Cartridges
plastic cartridge as smoothly as it does down the glass car­ whose plungers are flush with or extruded beyond the glass
tridge, leading to sudden spurts of administration of local of the cylindershould not be used. This problem is discussed
anesthetic, which can produce pain in the patient. Another later in this chapter (see"Problems").
problem with plastic cartridges is the fact that they are per­ An aluminum cap is located at the opposite end of the
meable to air. Exposure to oxygenleads to more rapid deg­ cartridge from the rubber plunger. It fits snugly around the
radation of the vasoconstrictor in the cartridge and to a neck of the glass cartridge, holding the thin diaphragm in
shorter shelf-life.2 position. It is silvercolored on most cartridges.
The diaphragm is a semipermeable membrane through
which the needle penetrates into the cartridge. When prop­
COMPONENTS erly prepared, the perforation of the needle is centrically
The prefilled 1.8-mLdental cartridge consists of four parts located and round, forming a tight seal around the needle.
(Fig. 7-2): Improper preparation of the needle and cartridge can
1. Cylindricalglasstube produce an eccentric puncture with ovoid holes leading to
2. Stopper (plunger,bung) leakage of the anesthetic solution during injection. The
101

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102 PART II The Armamentarium

TABLE 7-1
Color-Coding of Local Anesthetic Cartridges,
as per American Dental Association Council on
Scientific Affairs
LocalAnestheticSolution Colorof CartridgeBand
Articaine HCl 4% with
epinephrine 1: 100,000
Bupivacaine0.5% with
./ epinephrine 1:200,000
LidocaineHCl 2%
., LidocaineHCl 2% with
epinephrine 1:50,000
LidocaineHCl 2% with
epinephrine 1: 100,000
MepivacaineHCl 3%
MepivacaineHCI 2% with
levonordefrin 1:20,000
Prilocaine HCl 4%
Prilocaine HCl 4% with Yellow
epinephrine 1:200,000

Figure 7-1. 1.0, 1.8-(1.7-),and 2.2-mL cartridges together.

Aluminum cap Drug ldentlfytng Figure 7-3. Siliconerubber plunger is slightlyindented from the
color-<Xlded band rim of the glass.

Neck diaphragm is a semipermeable membrane that allows any


I solution in which the dental cartridge is immersed to diffuse
into the cartridge,thereby contaminating the localanesthetic
solution.
Persons with latex allergymay be at increased risk when
administered a local anesthetic through a glass cartridge.3
Rubber However, a recent literature review by Shojaei and Haas
diaphragm SIIicon rubber
plunger
stated that although the possibility of an allergic reaction
A precipitated by latex in the dental local anesthetic cartridge
does exist,"there are no reports of studies or casesin which
a documented allergy was due to the latex component of
cartridges for dental anesthesia."4
In recent years, latex-free dental cartridges have been
introduced.


A thin Mylar plastic label applied to all cartridges (Fig.
7-4) servesto (1) protect the patient and the administrator
in the event that the glasscracks, and (2) provide specifica­
tions about the enclosed drug. In addition, some manufac­
B
turers include a volume indicator on their labels,making it
Figure 7-2. A and B, Components of the glassdental local anes­ easier for the administrator to deposit precise volumes of
thetic cartridge. anesthetic (see Fig.7-4).

www.ShayanNemoodar.com
CHAPTER7 The Cartridge 103

0
septocame-
.
Lot number-.......... --Volume
,....
0

O
~
e Artlcalne HCI4% with
Epinephrine 1:100,000 Injection.
Contains sodium metabisulfite
C\l

'
Expiration date -
DIN number v
,.... SEPTOOONT
Proprietary name- 2'·Xylixaine·Df"•'­ France
Generlcname-- ~~~:.C~ 0)
,.._.__1.;1
:.-.•••..
""''··~·'·".__ .•••.:&.-'.
0 Lot: Exp:
!IA o..Jy .1•.
\:r,.,,. •••<:";·.· •:.-:-.;. •• -_, 1
lrot((l~i'~l •••..•••.••• """"'"
.•
f.•,. •• ,.,'r"Kt: ~

Manufacturer co m C'! ~
ci ci ,... ,...
A el I I I
Figure 7-4. Mylar plastic labd. Labd with volume indicator. (Courtesy Septodont, Lancaster,PA.)

TABLE 7-2
Composition of Local Anesthetic Solution
•Plain• Local
Anesthetic Vasopressor-Containing
Component Function Solution Local Anesthetic Solution
Local anesthetic drug (e.g.,lidocaine HCl) Blockadeof nerve conduction
Sodium chloride Isotonicity of the solution
Sterilewater Volume
Vasopressor(e.g.,epinephrine, t Depth and t duration of anesthesia;
levonordefrin) J. absorption of local anesthetic and
vasopressor
Sodium (meta)bisulfite Antioxidant
Methylparaben* Bacteriostaticagent
*Methylparabenis no longer included in single-usedental cartridges of local anesthetic; however,it is found in ALLmultidose vials of injectable drugs.

TABLE 7-3
Calculation of Milligrams per Cartridge
Percent Solution = Milligrams (mg} per Milliliter (ml) x Volume of Cartridge = Milligrams per Cartridge
0.5 = 5 x 1.8 = 9
1.0 = 10 x 1.8 = 18
2.0 = 20 x 1.8 = 36
3.0 = 30 x 1.8 = 54
4.0 = 40 x 1.8 = 72

(United Kingdom) (the number of milliliters in the car­


CARTRIDGE CONTENTS
tridge). Thus a 1.8-mL cartridge of a 2% solution contains
The composition of the solution found in the dental car­ 36 mg (Table7-3). The local anesthetic drug is stable and is
tridge variesdepending on whether a vasopressoris included capableof being autoclaved,heated, or boiled without break­
(Table7-2). ing down. However,other components of the cartridge (e.g.,
The local anesthetic drug is the raison d'etre for the entire vasopressor drug, cartridge seals) are more labile and are
dental cartridge. It interrupts the propagated nerve impulse, easilydestroyed.
preventing it from reaching the brain. The drug contained A vasopressor drug is included in most anesthetic car­
within the cartridge is listed by its percent concentration. tridges to enhance safety and the duration and depth of
The number of milligrams of the local anesthetic drug can action of the local anesthetic. The pH of dental cartridges
be calculatedby multiplying the percent concentration (e.g., containing vasopressorsis lower (more acidic) than that of
2% = 20 mg/mL) by the volume: 1.8 {UnitedStates) or 2.2 cartridgesnot containingvasopressors {pHof 3.S [3.3to 4.0]

www.ShayanNemoodar.com
104 PARTII The Armamentarium

vs. 6.5). Becauseof this pH difference,plain local anesthetics cultures taken immediately on opening a container usually
have a somewhat more rapid onset of clinicalaction and are fail to produce any growth. Therefore it seems obvious that
more comfortable (less"burning'' on lnjection)."? extraordinary measures related to cartridge sterilization are
Cartridges containing vasopressorsalso contain an anti­ unwarranted. Indeed, the glass dental cartridge should not
oxidant, most often sodium (meta)bisulfite.Sodium bisulfite be autoclaved.The seals on the cartridge cannot withstand
prevents oxidation of the vasopressorby oxygen,which can the extreme temperatures of autoclaving,and the heat-labile
be trapped in the cartridge during manufacture or can vasopressorsare destroyed in the process. Plastic cartridges
diffusethrough the semipermeablediaphragm (or the walls cannot be autoclaved.
of a plastic cartridge) after filling. Sodium bisulfite reacts Most commonly today,local anesthetics are marketed in
with oxygen before the oxygen is able to destroy the vaso­ cardboard boxes of approximately50 cartridges.Within the
pressor. When oxidized, sodium bisulfite becomes sodium box are 5 sealedunits of 10 cartridges each (Fig.7-5), called
bisulfate,having an even lower pH. The clinicalrelevanceof blister packs. Kept in this container until use, cartridges
this lies in the fact that increased burning (discomfort) is remain clean and uncontaminated.
experienced by the patient on injection of an "older" car­ Localanesthetic cartridgesshould be stored in their origi­
tridge of anesthetic with vasopressor compared with a nal container,preferablyat room temperature (e.g.,21° C to
fresher cartridge.Allergyto bisulfitesmust be considered in 22° C), and in a dark place. There is no need to "prepare" a
the medical evaluation of all patients before local anesthetic cartridge before use. The doctor or assistant should insert it
is administered'r"(see Chapter 10). into the syringe. However,many doctors feel compelled to
Sodium chloride is added to the cartridge to make the somehow"sterilize"the cartridge.When this urge strikes,the
solution isotonic with the tissues of the body. In the past, doctor should apply an alcohol wipe moistened with undi­
isolated instances have been reported in which local anes­ luted 91% isopropyl alcohol or 70% ethyl alcohol to the
thetic solutions containing too much sodium chloride rubber diaphragm (Fig. 7-6).
(hypertonic solutions) produced tissue edema or paresthe­ If a clearplastic cartridge dispenser is used, 1day'ssupply
sia, sometimes lasting for severalmonths, after drug admin­ of cartridges should be placed with the aluminum cap and
istration." This is no longer a problem. diaphragm facing downward. Several (two or three) sterile
Distilled water is used as a diluent to provide the volume dry 2 x 2-inch gauze wipes are placed in the center of the
of solution in the cartridge. dispenser and are moistened with (not immersed in) 91%
A significant change in cartridge composition in the isopropyl alcohol or 70% ethyl alcohol. No liquid alcohol
United States and in many other countries was the removal should be present around the cartridges. Beforethe syringe
of methylparaben, a bacteriostatic agent. A ruling by the is loaded, the aluminum cap and the rubber diaphragm are
Foodand DrugAdministration (FDA)mandated the removal rubbed against the moistened gauze.
of methylparaben from dental local anesthetic cartridges Cartridges should not be permitted to soak in alcohol or
manufactured after January 1, 1984. Methylparaben pos­ other sterilizing solutions because the semipermeable dia­
sessesbacteriostatic, fungistatic,and antioxidant properties. phragm allows diffusion of these solutions into the dental
It and related compounds (ethyl-, propyl-, and butylpara­ cartridge, thereby contaminating it. Therefore, it is recom­
ben) are commonly used as preservatives in ointments, mended that cartridges be kept in their original container
creams,lotions, and dentifrices.In addition, paraben preser­ until they are to be used.
vatives are found in all multiple-dose vials of drugs. Cartridge warmers are unnecessary.Indeed, occasionally
Methylparaben is commonly used in a 0.1% concentration they may produce problems. Overheating the local anes­
(1 mg/mL). Its removal from local anesthetic cartridges was thetic solution can lead to (1) discomfort for the patient
predicated on two facts. First, dental local anesthetic car­ during injection, and (2) the more rapid degradation of
tridges are single-use items meant to be discarded and not a heat-labile vasopressor (producing a shorter duration
reused. Therefore inclusion of a bacteriostatic agent is of anesthesia with more burning on injection). It has been
unwarranted. Second,repeated exposure to paraben has led demonstrated that after the warmed glass cartridge is
to reports of increasedallergicreactions in some persons.":" removed from the cartridge warmer and is placed in a
Responses have been limited to localized edema, pruritus, metal syringe with the solution forced through a fine metal
and urticaria. Fortunately,to date there has not been a sys­ needle, its temperature has decreased almost to room
temic allergicreaction to a paraben. Removalof methylpara­ temperature.2'5'13'14
ben has further decreasedan alreadyminimal risk of allergy Cartridge warmers, designedto maintain anesthetic solu­
to local anesthetic drugs. tions at "body temperature," are not needed and cannot be
recommended. Localanestheticsin cartridges maintained at
room temperature (20°C to 22° C) do not cause the patient
CARE AND HANDLING
any discomfort on injection into tissues, nor do patients
Local anesthetics are marketed in vacuum-sealed tin con­ complain of the solution being too cold.14 On the other
tainers of 50 cartridges and in blister packs of (usually) 10 hand, warmed local anesthetic solutions at 27° C or above
cartridges. Although no manufacturer makes any claim of have a much greater incidence of being described as too hot
sterility about the exterior surface of the cartridge, bacterial or burning on injection.13

www.ShayanNemoodar.com
CHAPTER 7 The Cartridge 105

2%Xylocaine'W•'Al
.,......,...._,.-.z~
~·Cl-...,.....
~.1.D".
b.""1y ~~.:~~~!~;·~·~
t;;:;. :-~;~~·,,
~-< ~1i.r.•1~

A B
Figure 7-5. A. Ten local anesthetic cartridges are contained in a sealed"blister pack."B, Back of blister pack contains information about
the drug.

1. Bubble in the cartridge


2. Extruded stopper
3. Burning on injection
4. Stickystopper
5. Corroded cap
6. "Rust" on the cap
7. Leakageduring injection
8. Broken cartridge

Bubble in the Cartridge


Figure 7-6. Preparing local anesthetic cartridge for use by A small bubble of approximately 1 to 2 mm diameter
wiping the rubber diaphragm with alcohol. (described as "BB"-sized)frequently is found in the dental
cartridge. It is composed of nitrogen gas,which wasbubbled
into the local anesthetic solution during its manufacture to
prevent oxygen from being trapped inside the cartridge,
Local anesthetic cartridges should not be left exposed to potentially destroying the vasopressor.The nitrogen bubble
direct sunlight because some contents may undergo acceler­ may not alwaysbe visiblein a normal cartridge (Fig.7-8, A).
ated deterioration. The primary clinicaleffectof this will be A largerbubble, which maybe present with a plunger that
destruction of the vasopressor,with a correspondingdecrease is extruded beyond the rim of the cartridge, is the result of
in the duration of clinicalaction of the anesthetic solution. freezing of the anesthetic solution (Fig. 7-8, B). Such car­
Included in everypackageof local anesthetic is an impor­ tridges should not be used, because sterility of the solution
tant document: the drug packageinsert. It contains valuable cannot be assured Instead, these cartridges should be
information about the product such as dosages,warnings, returned to their manufacturer for replacement.
precautions, and care and handling instructions. Allpersons
involvedin the handling or administration of localanesthet­ Extruded Stopper
ics should reviewthis document periodically (Fig.7-7). The stopper can become extruded when a cartridge is frozen
and the liquid inside expands. In this case, the solution
no longer can be considered sterile and should not be used
PROBLEMS for injection. Frozencartridges can be identifiedby the pres­
Occasionally problems develop with dental cartridges of ence of a large (>2 mm) bubble, along with an extruded
local anesthetics.Although most are minor, producing slight stopper.
inconvenience to the drug administrator, others are more An extruded stopper with no bubble is indicative of
significantand might prove harmful to the patient: prolonged storage in a chemical disinfecting solution and

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106 PART II The Armamentarium

WARNINGS
DENTAL PRACTITIONERS WHO EMPLOY LOCAL ANESTHETICS
IN THEIR OFFICES SHOULD BE WELL VERSED IN DIAGNOSIS
AND MANAGEMENT OF EMERGENCIES WHICH MIGHT ARISE
FROM THEIR USE. RESUSCITATIVE EQUIPMENT, OXYGEN, AND
OTHER RESUSCITATIVE DRUGS SHOULD BE AVAILABLE FOR
IMMEDIATE USE.
Reactions resulting in fatality have occurred on rare occasions with the use
of local anesthetics, even in the absence of a history of hypersensitivity.
8 1
Figure 7·7. A,Alllocal anesthetic containers have a product identificationpackageinsert, which should be read. B, Important information
is contained in all package inserts.

Figure 7-9. Extruded plunger on local anesthetic cartridge.

diffusion of the solution into the cartridge. Shannon and


Wescottdemonstrated that alcoholentersa cartridgethrough
the diaphragm in measurable amounts within 1 day if the
diaphragm is immersed in alcohol 15 Local anesthetic solu­
tions containing alcoholproduce an uncomfortable burning
on injection. Alcohol in sufficientlyhigh concentration is a
neurolytic agent capable of producing long-term paresthe­
B sia.The greatest concentration of alcohol reported to date in
Figure 7-8. A, Normal cartridge with no bubble or a small a dental cartridge has been 8% (Fig.7-9), which is not likely
BB-sizedbubble. Note that the rubber stopper is indented from the to produce significantlong-term injury.16
glass rim. B, Local anesthetic cartridge with an extruded stopper Antirust tablets should not be used in disinfectant solu­
and a large bubble caused by freezing. tions. The sodium nitrate (or similar agent) that they contain

www.ShayanNemoodar.com
CHAPTER7 The Cartridge 107

is capable of releasing metal ions, which have been related to


an increased incidence of edema after local anesthetic
administration.17
It should be remembered that small quantities of steril­
izing solution can diffuse into a dental cartridge with no
visiblemovement of the plunger. Care alwaysmust be taken
in storage of local anesthetic cartridges.

Burning on Injection
A burning sensation on injection of anesthetic solution may
be the result of one of the following:
1. Normal response to the pH of the drug
2. Cartridge containing sterilizingsolution
3. Overheated cartridge
4. Cartridge containing a vasopressor Figure 7-1 O. Local anesthetic cartridge with damaged cap. The
During the few seconds immediately after deposition of glass around the neck of the cartridge should be examined carefully
a local anesthetic solution, the patient may complain of a for cracks.
slight sensation of burning. This normal reaction is caused
by the pH of the local anesthetic solution; it lasts a second
or two, until the anesthetic takes effect,and is noted mainly
by sensitive patients when receiving local anesthetics con­ because the paraffin hardens on colder days. Using car­
taining epinephrine or levonordefrin. tridges at room temperature minimizes this problem; using
A more intense burning on injection is usually the result silicone-coated stoppers eliminates it. Plastic cartridges are
of diffusion of disinfectingsolution into the dental cartridge associated with this problem to a greater degree than glass
and its subsequent injection into the oral mucous mem­ cartridges.
branes. Although burning most often is a mere annoyance,
the inclusion of disinfectingagents such as alcohol in dental Corroded Cap
cartridges can lead to more serious sequelae,such as postin­ The aluminum cap on a local anesthetic cartridge can be
jection paresthesia and tissue edema.15•16 corroded if immersed in disinfecting solutions that contain
Overheating of the solution in a cartridge warmer may quaternary ammonium salts,such as benzalkonium chloride
produce burning on injection. The (Christmas tree) bulb­ (e.g.,"cold" sterilizing solution). These salts are electrolyti­
type cartridge warmer most often is at fault in this regard. cally incompatible with aluminum. Aluminum-sealed car­
Unlesslocal anesthetic cartridges are unusually cold,there is tridges should be disinfected in 91% isopropyl alcohol or
little justification for use of a cartridge warmer. Local anes­ 70% ethyl alcohol. Cartridges with corroded caps must not
thetic solutions injected at room temperature are well toler­ be used. Corrosion may be easily distinguished from rust,
ated by tissues and patients. which appears as a red deposit on an intact aluminum cap.
Use of a vasopressor-containinglocal anesthetic solution
may be responsiblefor the sensation of burning on injection. Rust on the Cap
The addition of a vasopressor and an antioxidant (sodium Rustfound on a cartridge indicatesthat at least one cartridge
bisulfite)lowersthe pH of the solution to approximately3.5, in the tin container has broken or leaked.The "tin" container
making it significantlymore acidic than solutions not con­ (actually steel dipped in molten tin) rusts, and the deposit
taining a vasopressor (pH about 6.5).5-7'17 Patients are more comes off on the cartridges. Cartridges containing rust
likely to feel the burning sensation with these solutions. A should not be used. If any cartridge contains rust a dented
further decrease in the pH of the local anesthetic solution cap, or a visible crack (Fig. 7-10), all cartridges in the con­
results as sodium bisulfite is oxidized to sodium bisulfate. tainer must be carefullycheckedbefore use.With the intro­
This response can be minimized by careful checking of the duction of nonmetal packaging,rust is rarely seen.
expiration date on all cartridges before use. Conversely,
increasingthe pH of the anesthetic solution has the effectof Leakage During Injection
making local anesthetic administration more comfortable Leakageoflocal anesthetic solution into the patient's mouth
for the patient,":" during injection occurs if the cartridge and the needle are
prepared improperly and the needle puncture of the dia­
phragm is ovoid and eccentric. Properly placed on the
Sticky Stopper syringe after the cartridge is inserted, the needle produces
The "sticky stopper" has become a rarity today, with the centric perforation of the diaphragm, which tightly seals
inclusion of silicone as a lubricant and the removal of itself around the needle. When pressure is applied to the
paraffin as a sealant in the cartridge. In caseswhere paraffin plunger during injection, all of the solution is directed into
is still used, difficulty in advancing the stopper may occur the lumen of the needle. If the cartridge is placed in a

www.ShayanNemoodar.com
108 PARTII The Armamentarium

Figure 7-11. Cracked glasson dental cartridge.

breech-loading syringe after the needle, an eccentric ovoid


perforation may occur; with pressure on the plunger, some
solution is directed into the lumen of the needle,while some
may leak out of the cartridge between the needle and the
diaphragm and run into the patient's mouth (see Fig.5-24). Figure 7-12. If force is necessaryto embed the harpoon in the
When the safetysyringe is used, it is necessaryto insert the rubber plunger,the glassfaceof the syringeshould be coveredwith
cartridgeafterthe needlehasbeen attached;however,because the hand.
the cartridge slides directly into the syringe, not from the
side,leakageduring injection is rarely a problem.Verbaland
written communications from doctors using plastic car­
tridges indicate that the occurrence of leakageappears to be Plastic cartridges do not fracture when subjected to PDL
considerablygreater when they are used. injection pressures.'
The plastic dental cartridge does not withstand the appli­ Excessiveforce used to engage the aspirating harpoon
cation of injection pressure as well as the traditional glass in the stopper has resulted in numerous cases of shattered
cartridge.Meechan and associatesapplied pressuresequal to cartridges. Although they have not broken in the patient's
those achieved during PDL injection with both glass and mouth, injury to dental personnel has been reported. Hitting
plastic local anesthetic cartridges.' Leakage of anesthetic the thumb ring of the syringe in an attempt to engage
occurred in 1.4% of glass cartridges, whereas leakage was the harpoon in the rubber stopper should be avoided.
noted in 75.1% of plastic cartridges. If this technique is essential to embed the harpoon in the
rubber plunger (as it is with the plastic safety syringe),
Broken Cartridge one hand should be used to cover the entire exposed
The most common cause of cartridge breakage is the use of glass face of the cartridge (Fig. 7-12). Proper preparation
a cartridge that has been cracked or chipped during ship­ of the armamentarium (see Chapter 9) minimizes this
ping. Dented metal containers and damagedboxesshould be problem.
returned to the supplier immediately for exchange. If a Breakagealso can occur as a result of attempting to use a
broken cartridge is found in a container, all remaining car­ cartridge with an extruded plunger. Extruded plungers can
tridges must be examined for hairline cracks or chips. Two be forcedback into the cartridge onlywith difficulty,if at all.
areas that must be examined carefullyare the thin neck of Cartridges with extruded plungers should not be used.
the cartridge where it joins the cap (see Fig. 7-10) and the Syringes with bent harpoons may cause cartridges to
glass surrounding the plunger (Fig. 7-11). Subjecting a break (see Fig.5-26). Bent needles that are no longer patent
cracked cartridge to the pressure of injection often causes create a pressure buildup within the cartridge during
the cartridge to shatter or "explode."If this occurs inside the attempted injection (see Fig. 5-25). No attempt should be
patient's mouth, serious sequelaemay result from ingestion made to force local anesthetic solution from a dental car­
of glass.It is essential to suction the patient's mouth thor­ tridge against significantresistance.
oughly and consult with a physician or emergency depart­
ment staff about follow-up therapy before discharging this
patient. The addition of a thin Mylarplasticlabelto the glass
RECOMMENDATIONS
cartridge minimizes such injury. Additionally,if the alumi­ 1. Dental cartridges must never be used on more than one
num "cap"on the cartridge is damaged,the cartridge should patient.
not be used, because the underlying glass may have been 2. Cartridges should be stored at room temperature.
damaged as well (see Fig. 7-10). 3. It is not necessaryto warm cartridges before use.

www.ShayanNemoodar.com
CHAPTER 7 The Cartridge 109

4. Cartridges should not be used beyond their expiration 8. Seng GF,Gay BJ:Dangers of sulfitesin dental local anesthetic
date. solutions: warning and recommendations, J Am Dent Assoc
5. Cartridges should be checked carefullyfor cracks, 113:769-770, 1986.
chips, and the integrity of the stopper and cap before 9. Perusse R, Goulet JP,Turcotte JY:Contraindications to vaso­
constrictors in dentistry. Part II. Hyperthyroidism, diabetes,
use.
sulfite sensitivity, cortico-dependent asthma, and pheochro­
mocytoma, Oral Surg 74:5687-5691, 1992.
References
10. NickelAA:Paresthesiaresulting from local anesthetics, J Oral
1. MeechanJG,McCabeJF,Carrick TE: Plasticdental anaesthetic MaxillofacSurg 42:52-79, 1984.
cartridges: a laboratory investigation, Br Dent J 169:254--256, 11. Wurbach G, Schubert H, Pillipp I: Contact allergy to benzyl
1990. alcoholand benzylparaben, Contact Dermatitis 28:3187-3188,
2. Meechan JG, Donaldson D, KotlickiA: The effect of storage 1993.
temperature on the resistance to failure of dental local 12. Klein CE, Gall H: Type N allergy to amide-type anesthetics,
anesthetic cartridges, J Can Dent Assoc 61:143-144, 147-148, Contact Dermatitis 25:145-148, 1991.
1995. 13. Volk RJ, Gargiulo AV:Local anesthetic cartridge warmer-first
3. SussmanGL,BeezholdDH: Allergyto latex rubber, Ann Intern in, first out, Ill Dent J 53:292-294, 1984.
Med 122:143-146, 1995. 14. RogersKB,FieldingAF,MarkiewiczSW:The effectof warming
4. Shojaei AR, Haas DA: Local anesthetic cartridges and latex localanestheticsolutionsprior to injection,Gen Dent 37:6496-
allergy:a literature review,J Can Dent Assoc 68:10622-10626, 6499, 1989.
2002. 15. Shannon IL,WescottWB:Alcoholcontamination oflocal anes­
5. JeskeAH, Blanton PL: Misconceptions involving dental local thetic cartridges, J Acad Gen Dent 22:20-21, 1974.
anesthesia. Part 2, Pharmacology.Tex Dent J 119:4310--4314, 16. OakleyJ: Personal communications, 1985.
2002. 17. Moorthy AP,Moorthy SP,O'Neil R: A study of pH of dental
6. Wahl MJ,Schmitt MM, Overton DA,Gordon MK:Injection of local anesthetic solutions, Br Dent J 157:11394--11395, 1984.
bupivacaine with epinephrine vs. prilocaine plain, J Am Dent 18. Crose VW: Pain reduction in local anesthetic administration
Assoc 133:111652-111656, 2002. through pH buffering, J Ind Dent Assoc 70:224--225, 1991.
7. Wahl MJ, Overton DA, Howell J, et al: Pain on injection of 19. Hanna MN, ElhassanA,VelosoPM, et al: Efficacyof bicarbon­
prilocaine plain vs. lidocaine with epinephrine: a prospective ate in decreasing pain on intradermal injection of local anes­
double-blind study, J Am Dent Assoc 132:101396-101401, thetics: a meta-analysis, Reg Anesth Pain Med 34:122-125,
2001. 2009.

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I

Additional Armamentarium
' I •I

In previous chapters, the three major components of the Application of a topical antiseptic is considered an
local anesthetic armamentarium-syringe, needle, and optional step in tissue preparation before intraoral injection.
cartridge-have been discussed.Other important items are
found in the local anesthetic armamentarium, however,
TOPICAL ANESTHETIC
including the following:
1. Topicalantiseptic Topical anesthetic preparations are discussed in depth in
2. Topicalanesthetic Chapter 4. Their use before initial needle penetration of the
3. Applicator sticks mucous membrane is strongly recommended. With proper
4. Cotton gauze (2 x 2 inches) application, initial penetration of mucous membrane any­
5. Hemostat where in the oral cavity can usually be made without the
patient's awareness.
For effectiveness,it is recommended that a minimal
TOPICAL ANTISEPTIC
quantity of topical anesthetic be applied to the end of
A topical antiseptic may be used to prepare the tissues at the the applicator stick and placed directly at the site of pene­
injection site before the initial needle penetration. Its func­ tration for approximately 1 minute. Gill and Orr have
tion is to produce a transient decreasein the bacterial popu­ demonstrated that when topical anesthetics are applied
lation at the injection site, thereby minimizing any risk of accordingto the manufacturer's instructions (approximately
postinjection infection. 10 to 15 seconds),their effectivenessis no greater than that
The topical antiseptic, on an applicator stick, is placed of a placebo, especially for palatal injections.4 Stern and
at the site of injection for 15 to 30 seconds. There is no Giddon showed that application of a topical anesthetic to
need to place a large quantity on the applicator stick; it mucous membrane for 2 to 3 minutes leadsto profound soft
should be sufficient just to moisten the cotton portion of tissue analgesia.5
the swab. A variety of topical anesthetic agents are available for
Availableagents include Betadine (povidone-iodine) and use today. Most contain the ester anesthetic benzocaine.
Merthiolate (thimerosal). Topical antiseptics containing The likelihood of occurrence of allergic reactions to esters,
alcohol (e.g., tincture of iodine, tincture of Merthiolate) though minimal, is greater than that to amide topical
should not be used because the alcohol produces tissue irri­ anesthetics; however, because benzocaine is not absorbed
tation. In addition, allergyto iodine-containing compounds systemically,allergic reactions are normally localized to
is common.P Beforeany iodine-containing topical antisep­ the site of application. Of the amides, only lidocaine pos­
tic is applied to tissues,the patient should be questioned to sesses topical anesthetic activity in clinically acceptable
determine whether adverse reactions to iodine have previ­ concentrations. The risk of overdose with amide topical
ously developed. anesthetics is greater than that with the esters and increases
In a survey of local anesthetic techniques in dental prac­ with the area of application of the topical anesthetic.Topical
tice,3 7.9% of dentists mentioned that they always used forms of lidocaine are available as ointments, gels, pastes,
topical antiseptics before injection, 22.4% sometimes used and sprays.
them, and 69.7% never used them. EMLA(eutectic mixture of local anesthetics) is a combi­
Postinjectioninfectionscan and do occur,and regularuse nation oflidocaine and prilocaine in a topical cream formu­
of a topical antiseptic can virtually eliminate them. If a lation, designed to provide surface anesthesia of intact skin.
topical antiseptic is not available,a sterile gauzewipe should Its primary indications are for use before venipuncture and
be used to prepare the tissues adequatelybefore injection. in pediatric surgical procedures, such as circumcision.6•7
110

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CHAPTER8 Additional Armamentarium 111

Figure 8-1. Disposablenozzle for topical anesthetic spray. Figure 8-2. Cotton-tipped applicator sticks.

EMLAhas been used effectivelyintraorally;however,it is not


COTTON GAUZE
designed for intraoral administration, so it contains no fla­
voring agent and is bitter tasting.8•9 Cotton gauze is included in the local anesthetic armamen­
Unmetered sprays of topical anesthetics are potentially tarium for (1) wiping the area of injection before needle
dangerous and are not recommended for routine use. penetration and (2) drying the mucous membrane to aid in
Becausetopical anesthetics require greater concentration to soft tissue retraction for increased visibility.
penetrate mucous membranes, and because most topical Many dentists select gauze in lieu of topical antiseptic
anesthetics are absorbed rapidly into the cardiovascular solution for cleansing the soft tissue at the site of needle
system,only small measured doses should be administered. penetration. Gauze effectivelydries the injection site and
Topicalanesthetic spraysthat delivera continuous stream of removes any gross debris from the area (Fig. 8-3). It is not
topical anesthetic until being deactivated are capable of as effective as the topical antiseptic but is an acceptable
delivering overly high doses of the topical anesthetic. If substitute.
absorbed into the cardiovascularsystem,the resulting anes­ Retraction of lips and cheeksfor improved accessto, and
thetic blood level may approach overdose levels. Metered visibilityof, the injection site is important during all intra­
sprays that deliver a fixed dose with each administration, oral injections. Often this task becomes unnecessarilydiffi­
regardless of the length of time the nozzle is depressed, are cult if these tissues are moist, and it is made even more
preferred for topical formulations that are absorbed systemi­ vexingby wearinggloves.Dry cotton gauzemakesthe tissues
cally.An example of this form of topical anesthetic spray is easier to grasp and to retract.
Xylocaine,which delivers 10 mg per administration. A variety of sizesof cotton gauze are availablefor tissue
Yet another potential problem with topical anesthetic retraction, but the most practical and the most commonly
sprays is difficultykeeping the spray nozzle sterile.This is a used is the 2 x 2-inch size. Note that when gauze is placed
veryimportant consideration when the form of topical anes­ intraorally to stop bleeding, it is recommended that 2 x
thetic to be used is selected.Most topical anesthetic sprays 2-inch squares not be used. Larger,4 x 4-inch gauze squares
today come with disposable applicator nozzles (Fig.8-1). are much preferred Additionally,whenever gauze is placed
It must be remembered that some topical anesthetic for­ into and left in the mouth for a period of time, a length of
mulations contain preservatives,such as methylparaben, and dental floss should be tied around it, so that the gauze may
other ingredients that may be significant in instances of be removedor retrievedfrom the mouth quickly,if necessary
allergyto local anesthetics. (Fig.8-4).

APPLICATOR STICKS HEMOSTAT


Applicator sticks should be available as part of the local Although not considered an essential element of the local
anesthetic armamentarium. They are wooden sticks with a anesthetic armamentarium, a hemostat or pickup forceps
cotton swab at one end They can be used to apply topical should be readily availableat all times in the dental office.
antiseptic and anesthetic solutions to mucous membranes Its primary function in local anesthesia is removal of a
(Fig. 8-2) and compress tissue during palatal injections. needle from the soft tissues of the mouth in the highly

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112 PARTII The Armamentarium

Figure 8-3. Sterile gauze is used


(A) to wipe the mucous membrane at
the site of needle penetration and (B)
to aid in tissueretraction if necessary.

Figure 8-4. Flosstied around a gauze square aids easyretrieval.

Figure 8-5. Hemostat

unlikely event that the needle breaks off within tissues 5. Stem I, Giddon DB: Topical anesthesia for periodontal proce­
(Fig. 8-5). dures, Anesth Prog 22:105--108, 1975.
6. Fetzer SJ: Reducing venipuncture and intravenous insertion
pain with eutectic mixture of local anesthetic: a meta-analysis,
References Nurs Res 51:119--124, 2002.
1. Bennasr S, Magnier S, Hassan M, et al: Anaphylacticshock and 7. TaddioA:Pain management for neonatal circumcision,Paediatr
low osmolarity contrast medium, Arch Pediatr 1:155--157, 1994. Drugs 3:101-111, 2001.
2. Palobart C, Cros J,Orsel I, et al:Anaphylacticshockto iodinated 8. Bernardi M, SeccoF,BenechA;Anesthetic efficacyof a eutectic
povidone, Ann Fr Anesth Reanim 28(2):168--170, 2009. mixture oflidocaine and prilocaine (EMLA)on the oral mucosa:
3. Malamed SF:Handbook oflocal anesthesia,ed 1, St Louis, 1980, prospectivedouble-blind study with a placebo,Minerva Stoma­
Mosby. tol 48:39--43, 1999.
4. Gill CJ, Orr DL II: A double blind crossover comparison of 9. Munshi AK,HegdeAM,Latha R:Useof EMLk is it an injection
topical anesthetics,J Am Dent Assoc 98:213--214, 1979. free alternative?J Clin Pediatr Dent 25:215--219, 2001.

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Preparation of the
Armamentarium

Proper care and handling of the local anesthetic armamen­ harpoon in the rubber stopper-a process that can lead to
tarium can prevent or at least minimize the development broken glasscartridges or leakageof anesthetic solution into
of complications associated with the needle, syringe, and the patient's mouth during the injection. The recommended
cartridge. Many of these have been discussedin the preced­ sequence,as alreadydescribed,virtually eliminatesthis pos­
ing chapters. Other complications and minor annoyances sibility and should alwaysbe used.
may be prevented through proper preparation of the
armamentarium. Recapping the Needle
After removal of the syringe from the patient's mouth, the
needle should be recapped immediately.Recappingis one of
BREECH-LOADING, METALLIC OR PLASTIC, the two times when health professionals are most likely to
CARTRIDGE-TYPE SYRINGE be injured (stuck) with a needle*; it is probably the most
1. Removethe sterilizedsyringe from its container dangerous time to be stuck because the needle is now con­
(Fig. 9-1). taminated with blood, saliva,and debris.Although a variety
2. Retract the piston fullybefore attempting to load the of techniques and devicesfor recappinghavebeen suggested,
cartridge (Fig.9-2). the technique recommended by most state safetyand health
3. Insert the cartridge, while the piston is fully retracted, agencies is termed the scoop technique (Fig. 9-7), in which
into the syringe.Insert the rubber stopper end of the the uncapped needle is slid into the needle sheath lying on
cartridge first (Fig.9-3). the instrument tray or table. Until a better method is
4. Engagethe harpoon. While holding the syringe as if designed, the scoop technique should be used for needle
injecting, gentlypush the piston forward until the recapping.
harpoon is firmly engaged in the plunger (Fig.9-4). Safetyneedles and syringesfor use in dentistry are still in
Excessiveforce is not necessary.Do NOT hit the piston their developmental stage.Most systems currently available
in an effort to engagethe harpoon because this for dental use leavemuch to be desired.
frequently leads to cracked or shattered glasscartridges Various needle cap holders are available--commercially
(Fig. 9-5). made (Fig.9-8) or self-made (from acrylic)-that hold the
5. Attach the needle to the syringe.Removethe white or cap stationary while the needle is being inserted into it,
clear protective plastic cap from the syringe end of the making recapping somewhat easier to accomplish.
needle and screwthe needle onto the syringe (Fig.9-6).
Most metal and plastic hubbed needles are prethreaded, Unloading the Breech-Loading, Metallic or
making it easyfor them to be screwedonto the syringe; Plastic, Cartridge-Type Syringe
however,some plastic hubbed syringesare not After administration of the local anesthetic, the following
prethreaded, requiring the needle to be pushed toward sequence is suggestedfor removing the used cartridge:
the metal hub of the syringe while being turned. 1. Retract the piston and pull the cartridge awayfrom the
6. Carefullyremove the colored plastic protective cap from needle with your thumb and forefinger as you retract
the opposite end of the needle, and expel a few drops of the piston (Fig.9-9), until the harpoon disengagesfrom
solution to test for proper flow. the plunger.
7. The syringe is now ready for use.
Note: It is common practice in dentistry to attach the *The other common time for needle-stick injury is during injection, when
needle to the syringe before placing the cartridge. This a finger of the opposite hand is accidentally stuck as a result of sudden
sequence requires hitting the piston hard to engage the unexpected patient movement.

113

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114 PART II The Armamentarium

-· '..,l~f,..,,,,.,.,. -·
Figure 9-1. Localanesthetic arm­
;.
' H!).t,~-.i1;•,•••• - • • t

amentarium (from top): needle, car­


tridge, syringe.

Figure 9-2. Retract the piston.

Figure 9-3. Insert the cartridge.

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CHAPTER 9 Preparation of the Armamentarium 115

Figure 9-4. Engagethe harpoon in the plunger with gentle finger pressure.

Figure 9·5. Do not exert force on the plunger; the glass may crack.

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Figure 9-6. If the plastic hubbed
needle is not prethreaded, it must be
screwed onto the syringe while
simultaneously being pushed into
the metal needle adaptor of the
syringe.

Figure 9- 7. "Scoop"technique for


recapping a needle after use.

Figure 9-8. Plastic needle cap holder.

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CHAPTER 9 Preparation of the Armamentarium 117

Figure 9-9. Retract the piston.

Figure 9-10. Removethe used cartridge.

PLACING AN ADDITIONAL CARTRIDGE IN


2. Removethe cartridge from the syringe by inverting
A (TRADITIONAL) SYRINGE
the syringe,permitting the cartridge to fall free
(Fig. 9-10). On occasionit is necessaryto deposit an additional cartridge
3. Properly dispose of the used needle.All needles must be oflocal anestheticsolution.Todo this,the followingsequence
discarded after use to prevent injury or intentional is suggested with the metallic or plastic breech-loading
misuse by unauthorized persons. Carefullyunscrew the syringe:
now recapped needle, being careful not to accidentally 1. Recapthe needle using the scoop (or other appropriate)
discard the metal needle adaptor (Fig.9-11). The use of technique, and remove it from the syringe.
a sharps container is recommended (Fig.9-12) for 2. Retract the piston (disengagingthe harpoon from the
needle disposal. rubber stopper).

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118 PARTII The Armamentarium

Figure 9·11. When discarding the needle, check to be sure that the metal needle adaptor from the syringe is not inadvertently discarded
also (arrow).

3. Removethe used cartridge.


4. Insert the new cartridge.
5. Embed the harpoon.
6. Reattach the needle.
The estimated time necessaryto complete this procedure
is 10 to 15 seconds.

SELF-ASPIRATING SYRINGE*
1. Insert the cartridge (as in the preceding instructions).
2. Attach the needle.
3. The syringe is now ready for use.
Becauseof the absenceof a harpoon, loading and unload­
ing the self-aspiratingsyringe are simple procedures.

ULTRASAFEASPIRATING SYRINGEt
Loading the Safety Syringe
1. While gripping the barrel firmly,fully insert the
anesthetic cartridge into the open end of the injectable
system (Fig.9-13).
2. Grip the plunger handle, putting the thumb behind the
finger holder. Introduce the handle tip into the barrel
of the injectable system,behind the cartridge
(Fig.9-14).
Figure 9-12. A, A sharps container is required for storage of 3. Next, slide the sheath protecting the needle backward,
discarded contaminated needles. B, A separate sealed container is toward the handle, until it CLICKS(the click is made as
recommended for discarded local anesthetic cartridges.
*From Dentsply,www.dentsply.com.This is a portion of the instructions
that Dentsply encloseswith its syringes.
tFrom SafetySyringes,Arcadia, Calif (www.safetysyringes.com).This is a
portion of the instructions that SafetySyringesencloseswith its syringes.

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CHAPTER 9 Preparation of the Armamentarium 119

Figure 9-13. Insert the local anesthetic cartridge into the safety Figure 9-16. Remove the needle cap and discard. (Courtesy
syringe. (Courtesy Septodont, Inc., Lancaster,PA.) Septodont, Inc., Lancaster,PA.)

Figure 9-14. Introduce the handle tip into the barrel of the
injectable system,behind the cartridge. (Courtesy Septodont, Inc.,
Lancaster,PA.)

B
Figure 9-17. A. Passiveaspiration. B, Activeaspiration. (Cour­
tesy Septodont, Inc., Lancaster,PA.)

a depression occurs, and when released (injection stopped),


the diaphragm movesback awayfrom the protuberance and
aspiration occurs (Fig. 9-17,A).

Active Aspiration. Activeaspiration is obtained by the sili­


cone top of the plunger handle creating a vacuum when,
thumb in ring, the practitioner pulls back (Fig.9-17,B).The
Figure 9-15. While protecting the needle, slidethe sheath back­ bung follows the plunger tip, providing active aspiration,
ward toward the handle until it CLICKS.(CourtesySeptodont,Inc., which is best observedwhen a minimum of 0.25to 0.35 mL
Lancaster,PA.) of solution (providing space)has been expelledor used from
the cartridge.
5. When using only one cartridge:
the sheath hits the handle and locks the unit together) Note: During multiple injection procedures using one
(Fig. 9-15). cartridge, the practitioner may safelyretain the syringe
4. All movements now are awayfrom the needle. Remove for further use by moving the sheath toward the needle
the needle cap and discard. The system is now ready to until it reaches the holding position (Fig.9-18). Should
use (Fig.9-16). you need to insert a second cartridge, follow from step 7
onward.
Aspiration To complete the procedure, slide the protective sheath
Passive Aspiration (Self-Aspiration). At the base of the car­ toward the locking position, which is the second notch at
tridge barrel of the injectable system,you will see there is a the end of the barrel (Fig.9-19, A and B). This has now
small protuberance. It appears as a blob of glue holding the locked the needle safelyin the protective sheath.
centered needle, the needle-end that penetrates the dia­ 6. Removethe plunger handle after use.After you have
phragm of the cartridge when inserted. At the start of the locked the injectable system in the (B) position, hold
injection,the diaphragm is pressedagainstthe protuberance; the barrel of the injectable systemwith one hand, and,

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120 PARTII The Armamentarium

Figure 9·18. Move the sheath toward the needle until it reaches the 'A'
holding position (A) so that the syringe may be used again. (Courtesy
Septodont, Inc., Lancaster,PA.)
"""/

Figure 9-19. A, To lock the syringe, slide the protective sheath


A
toward the locking position (B), which is the second notch at the end
of the barrel. B, Locked safety syringe. (Courtesy Septodont, Inc.,
Lancaster,PA.)

Figure 9·20. Removethe plunger handle after use.After locking the


injectable system in the (B) position (see Fig. 9-19, A), hold the barrel
of the injectable system with one hand, and while using the other
hand, place a fingerin the ring of the plunger handle and pull backward
until the plunger is fully retracted. After you have fully retracted the
plunger, peel off the handle in one movement. (Courtesy Septodont,
Inc., Lancaster,PA.)

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CHAPTER 9 Preparation of the Armamentarium 121

while using the other hand, place a finger in the ring of Hold the barrel of the injectable system with one hand,
the plunger handle and pull backward until the plunger and, while using the other hand, place a finger in the ring
is fully retracted. After you have fully retracted the of the plunger handle and pull backward until the plunger
plunger, peel off the handle in one movement (Fig. is fully retracted. Now that you have fully retracted the
9-20). Now the injectable system can be disposed of plunger, peel off the handle in one movement.
safely and the handle autoclaved. 8. Take hold of the plunger handle of the injection system,
7. When inserting a second cartridge: and pull the grip handle back toward the ring. Now
Note: During procedures that require more than one insert the tip of the plunger into the empty cartridge,
cartridge, retract the sheath to the holding position (A) as which is inside the injectable system. Pull out the
a needle-stick prevention device. Should the system be cartridge attached to the plunger by the silicone tip,
inadvertently fully locked into position (B), no attempt remove the cartridge from the plunger, and dispose of
whatsoever should be made to unlock it. Use a new injection safely. You are now ready to insert a fresh cartridge and
system. proceed as from step 1.

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IN THIS PART
Chapter 10 Physical and Psychological Evaluation
Chapter 11 Basic Injection Technique
Chapter 12 Anatomic Considerations
Chapter 13 Techniques of Maxillary Anesthesia
Chapter 14 Techniques of Mandibular Anesthesia
Chapter 15 Supplemental Injection Techniques
Chapter 16 Local Anesthetic Considerations in
Dental Specialties

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PART
Techniques of Regional
Anesthesia in Dentistry
The anatomy of the head, neck, and oral cavityis presented as a prelude to detailed descriptions of the
techniques of regional anesthesia. Techniques that are commonly used in dentistry are presented.
Although many of the techniques described in these chapters also may be carried out successfullywith
an extraoral approach, the author has limited descriptions to intraoral techniques, primarily because
of the extremelylimited use of extraoral nerve blocks in contemporary dental practice. The interested
reader is referred to textbooks that describe extraoral techniques at some length.1•2
Eachinjection technique usuallyhas severalvariations. Subtledifferencesare noted when techniques
are taught to students by different persons. The reader must alwayskeep in mind that there is never
only one "correct" technique. Goals in the administration of local anesthesia are to provide clinically
adequate pain control without unnecessarily increasing risk or provoking any immediate or delayed
complicationsin the patient. Any technique that meets these two criteria is acceptable.The techniques
presented in this section are those that this author finds most acceptable.In severalsituations, alterna­
tive approaches to the technique are also described.
A subject that is all too often neglected-the requirements for pain control and local anesthesia
within the dental specialties-is discussed after these basic injection techniques are described. These
requirements vary somewhat from endodontics to pediatric dentistry to periodontics to prosthodontics
to oral and maxillofacialsurgery and require special attention (Chapter 16).Administration of local
anesthetics to the geriatric patient, a significant and growing segment of the population, is also
reviewed.
The beginning of this section, Chapters 10 and 11, addressestwo important subjects related to all
injections:the physicaland psychologicalevaluation of the patient before injection and basic injection
technique (e.g., preparation of the patient and tissues for administration of any local anesthetic, the
procedure for an atraumatic [painless]injection).

References
1. Hadzic A, Vloka JD: Peripheral nerve blocks: principles and practice, New York, 2004, McGraw-Hill.
2. Chelly J: Peripheral nerve blocks: a color atlas, ed 3, Philadelphia, 2009, Lippincott Williams &: Wtlldns.

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I

hysical and Psychological


Evaluation
' I •I

Beforestarting any dental procedure, the doctor or hygienist physical examination of the patient. Adequate use of these
must determine whether the patient can tolerate the planned tools can lead to an accurate determination of a patient's
dental procedure in relativesafety.If this is not the case,the physical status and can prevent up to 90% of all life­
specific treatment modifications necessary to decrease the threatening medical emergenciesin dental practice.2
risk presented by the patient must be determined. This is
especiallyimportant whenever drugs are to be administered
during treatment, such as analgesics,sedatives, inhalation
GOALS OF PHYSICAL AND
sedation (N20-02) agents, and local anesthetics. Before
PSYCHOLOGICAL EVALUATION
administering local anesthetics, the administrator must In the followingdiscussion,a comprehensivebut easy-to-use
determine the relative risk presented by the patient. This is program of physical evaluation is described.3•4Used as rec­
important because local anesthetics, like all drugs, exert ommended, it allows the dental team to accurately deter­
actions on many parts of the body (see Chapter 2). Actions mine any potential risk presented by the patient before the
of local anesthetics include depressant effects on excitable start of treatment. This system can be used to meet the fol­
membranes (e.g., central nervous system [CNS],cardiovas­ lowing goals:
cular system [CVS]).Becauselocal anesthetics undergo bio­ 1. To determine the patient's ability to tolerate physically
transformation primarily in the liver (amides) or blood the stressesinvolvedin the planned dental treatment
(esters) the functional status of these systemsmust be deter­ 2. To determine the patient's ability to tolerate
mined before drug administration. Becausea small percent­ psychologically the stressesinvolvedin the planned
age of all injected local anesthetic is excreted in an active dental treatment
(unmetabolized) form in the kidneys,kidney function must 3. To determine whether treatment modification is
be evaluated. Other questions should be asked: Has the indicated to enable the patient to better tolerate the
patient ever receiveda local anesthetic for medical or dental stressesof dental treatment
care?If so, were any adversereactions observed? 4. To determine whether the use of psychosedation is
Most undesirable reactions to local anesthetics are pro­ indicated
duced not by the drugs themselvesbut as a response to the 5. To determine which technique of sedation is most
act of drug administration.1 These reactions are commonly appropriate for the patient
psychogenic and have the potential to be life threatening 6. To determine whether contraindications exist to (a) the
if not recognized and managed promptly. The two most planned dental treatment or (b) any of the drugs to be
commonly occurring psychogenic reactions are vasode­ used.
pressor syncope and hyperventilation. Other psychogeni­ The first two goalsinvolvethe patient's ability to tolerate
callyinduced reactionsnoted as a responseto localanesthetic the stress involvedin the planned dental care. Stressmay be
administration may include tonic-clonic convulsions,bron­ of a physiologic or psychological nature. Patients with
chospasm, and angina pectoris. underlying medical problems may be lessable to tolerate the
However,local anesthetics are not absolutely innocuous usual levelsof stress associatedwith various types of dental
drugs, nor is the act of local anesthetic administration care. These patients are more likely to experience an acute
entirely benign. The doctor must seek to uncover as much exacerbation of their underlying medical problem(s) during
information as possibleconcerningthe patient's physicaland periods of increased stress. Such disease processes include
mental status before administration of a local anesthetic. angina pectoris, seizure disorders, asthma, and sickle cell
Fortunately the means to do so exist in the form of the disease. Although most of these patients will be able to
medical history questionnaire, the dialogue history, and the tolerate the planned dental care in relative safety,it is the
124

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CHAPTER 10 Physicaland PsychologicalEvaluation 125

obligation of the dental team to determine whether a Many types of medical history questionnaires are avail­
problem does exist and the severity of the problem and to able; however,most are simply modifications of two basic
decide how it might impact the proposed dental treatment types: the "short" form and the "long" form. The short form
plan. medicalhistory questionnaire providesbasic medicalhistory
Excessive stress can prove detrimental to the non­ information and is best suited for use by a dentist or hygien­
medically compromised (i.e., "healthy") patient. Fear, ist with considerable clinical experience in physical evalua­
anxiety, and acute pain produce abrupt changes in the tion. When using the short-form history, the dentist or
homeostasis of the body that may prove detrimental. Many hygienistmust have a firm grasp of the appropriate dialogue
"healthy" patients suffer from fear-related emergencies, history required to aid in determination of the relative risk
including hyperventilation and vasodepressor syncope (also presented by the patient. The dentist or the hygienistshould
known as vasovagal syncope and "fainting"). be experienced in the use of techniques of physical evalua­
The third goal is to determine whether the usual treat­ tion and interpretation of findings. Unfortunately, most
ment regimen for a patient should be modified to enable the dentist offices use the short form or a modification of it
patient to better tolerate the stress of treatment. In some primarily as a conveniencefor their patient and themselves.
cases, a healthy patient will be psychologically unable to The long form, on the other hand, results in a more detailed
tolerate the planned treatment. Treatment may be modified database concerning the physical condition of the prospec­
to minimize the stress faced by this patient. The medically tive patient. It is used most often in teaching situations and
compromised patient will also benefit from treatment modi­ represents a more ideal instrument for teaching physical
fication aimed at minimizing stress. The stress reduction evaluation.
protocols (SRPs) outlined in this chapter are designed to aid In recent years, computer-generated medical history
the dentist and the hygienist in minimizing treatment­ questionnaires have been developed.5 These questionnaires
related stress for both healthy and medically compromised permit patients to enter their responses to questions elec­
patients. tronically on a computer. Whenever a positive response is
When it is believed that the patient will require some given,the computer asks additional questions related to the
assistance in coping with his or her dental treatment, the use positive response. In effect,the computer asks the questions
of psychosedation should be considered. The last three goals called for in the dialogue history.
involve determination of the need for use of psychosedation, Any medical history questionnaire can prove to be
selection of the most appropriate technique, and selection of extremelyvaluable or entirelyworthless.The ultimate value
the most appropriate drug(s) for patient management. of the questionnaire resides in the ability of the dentist or
hygienist to interpret the significanceof the answers and to
elicit additional information through physical examination
PHYSICAL EVALUATION and dialogue history.
The term physical evaluation is used to describe the steps In this sixth edition of Local Anesthesia, the prototypical
involved in fulfilling the aforementioned goals. Physical adult health history questionnaire that has been developed
evaluation in dentistry consists of the following three by the University of the Pacific {UOP) School of Dentistry
components: in conjunction with MetLifehas been included (Fig. 10-1).6
1. Medicalhistory questionnaire Figure 10-2 is an example of a pediatric medical history
2. Physicalexamination questionnaire.
3. Dialogue history This health history has been translated into 36 different
With the information (database) collected from these languages,constituting the languagesspoken by 95% of the
three steps, the dentist and the hygienist will be better able persons on this planet. The cost of the translation was sup­
to (1) determine the physicaland psychologicalstatus of the ported by several organizations including the California
patient (establish a risk factor classificationfor the patient); Dental Association,but most extensivelyby MetLifeDental.
(2) seek medical consultation, if indicated; and (3) appro­ The health history (see Fig. 10-1),translations of the health
priately modify the planned dental treatment, if indicated. history (Fig. 10-3), the interview sheet (Fig. 10-4), the
Each of the three steps in the evaluation processis discussed medical consultation form (Fig. 10-5), and protocols for
in generalterms, with specificemphasisplaced on its impor­ the dental management of medically complex patients
tance in the evaluation of the patient for whom local anes­ may be found on the University of the PacificWebsite at
thesia is to be administered. www.dental.pacific.eduunder "Dental Professionals" and
then under "Health History Forms."Protocols for the man­
Medical History Questionnaire agement of medicallycomplex patients can be found at the
The use of a written, patient-completed medical history sameWebsiteunder "PacificDental Management Protocols."
questionnaire is a moral and legal necessity in the practice Translations of the medical history form can be found at
of both medicine and dentistry.Suchquestionnaires provide www.metdental.comunder "Multilanguage Medical Health
the dentist and the hygienist with valuable information History Forms Available."
about the physicaland in some casesthe psychologicalcon­
dition of the prospectivepatient. Text continued on p. 131

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126 PART III Techniques of Regional Anesthesia in Dentistry

MetLife HEAL TH HISTORY UniYtraity of the Pacific


English
Pu:imllNunc: f'Mimt ld1miric:alionl'\.&mlxr:
Huth o.h!:
I. CIRCLE APPROPRIATE A'.\"SWER(lnn:blenk ir,ou do not undcislllld queslionJ:
I. Yes l'\o byo;irgaEtal Kalthguod?
2. Yes Xo I la lhcA:bc:al • ehlqp: in ,our llCll.11• witlin Ille1151,.:al'?
l. Yes l'\o I la...: )'Oll'1eal klspillli"o.:dor hid a serious illness in 1~ loll lhR."C ,.:ari!
lfYL~.wl!J? __ -:-:----:---:-:-----:::-:-----::-::-----------------~
4. Yes l'\o Are JUll~ ~by a ph)'Sicillnnow? ror wllor!
n.ie or ••• mecical euim? Dale oflmdeial exam ----------
!i. Yts l'\o I law )'OII Ia! pmblem!lwilh prior denial 1rm1111e11P.
6. Yes Xo An=JU11in pain llDW"!
II. HAVE YOU iXPERIEftCED:
1. y.,,. l'\u ( ,~ pain.l•.PiaY! 18. y"' Nu DW:i1ins'!'
II. Yts Xo Swolen utles?
Shonnc:!l!ll or ix.di?
19. y"' Ko Ringing inan"!
It. Yts l'\"o ?O. Ya No I~?
ID. Yts l'\o Ra:ml wagtit llm. '-"· mpl swats"! 21. Ya No Fainq sp=lb?
II. Yes l\'o Pl:oisu:m.cuugh. '-"UUJhing up bkloll? 22. Yes No llluncd ~iliun?
t?. Yes l'\o Bh:l:d"q:prubkmL bruising msily? 21. Yts Nu Sci".aiR:li?
IJ. Yes l'\o Siiu pruttems? 24.. Ya; No EAwisive tbilSl?
14. Yes l'\o DilTieullyswallvwi~ u. Yo No Fiap:nl urinatioo?
1::1. Yes l'\o DllPdlco.cvnsllpatloll. blood In SIOO~ Z6. Yes Xo Ory IDOUll""!
16. Yes Ko f'~l-itilt:. naisca"! 71. Yes ~ Jaundice?
l"l. Yts l\o llilli.:ullJ' ·mnM1111. blood •• 111"1.e? :!IL Yes :\o Joint pain. Slllfnc:ss"!
Ill. DO YO(; HAYt: OR HAYli: YOU HAD:
29. Yes Ko lkar:~ 40. Yes Ko AIDS
JO. Ye Ko I kar: llli.ck.'-rt dob:tl? 41. Ye No Tumn.canocl'!
JI. Yes l'\o I!ear. nurQln? 42. Yes Xo Anm1is,, lhcumltism?
J2. Yes R~li:•-.:r?
l'\o 4J. Yc:o No ~iti-3!
]]. Yts l'\o
Snub. lwdeniiw of 11'ter'im? 44. Yes No Skin di&eacs?
34. Ya l ligh bhoodpn:mun:"!
l'\o 45. Yc:o l'io Anl:ni..?
ls. Ya l'\o
Aslluna. ·1u. 11m.,l17seam.
admr kuig lilem? 46. Yes l'\o Yll ISJphilisur gulllllrhmP.
)6. Ya l\'o
I k:pmitia.vlhs:r.iov ob:mi.-? -47. y"' No lk:rpu".'
l1. Yes l'\o
S1c11111Cbpublem. ukzn? 4&. Yn No Kidm=y.baklenliS1111R.-?
Ja. y.,,. Alkigb Id:: di..,_ l<ub. 1:..W.:Uiui.._!au:>.?
l'\u -19. Ya. l'\u TbJ1uiil.••••.,•••••.•~
39. Yts l'\o
Fmnily hilitmyor dWims. '-t
probl!ims.IUmori! so. Yn No IYialiem?
IV. DO YOl.! llAYt: OR llAVK YOU HAD:
51. Yes l'\o 1'5)diokK-eani" S6. Yn Xo Huspilalinl.ion?
5?. Yes l'\o R.-lidion ln:aunenls? 51. Yn Xo Blood kllllirusium?
51. Yeo l'\n nie.a.11betap,? !Ill y.,. Xn s.~
54. Yes l'\o PRlsdtcl:iellCll.n~we? 59. Yo No Paccnnkel'!
SS. Yes Ko Anir.cillljoinl? 60. Yes No Conllll:llmses?
V.ARE YOUTAKl:"llG:
61. Yts l\o IWcRallODlldrugs"! 6J. Yn i\o Iobaa:o iI 811)" form"!
62. Yts l'\o Drup. mcdicalions. C1¥C1"-llr-<o.111Cr
llCdicnes 64. Yn l'io Alcdtol?
Cinc:ladiagaspim). n11ura1~ills?
l'leail=list

\"I.WO:WF.'lrti 0:\1.Y:
M. Yc:s l'\o An=JUU IX coul• JOU bl=pRflWll or n1miiqf. 66. Ya No Takmg billh i:omol Fills?
\'II. Al.I. P:\TH:.,lS:
61. Yes l'\o llu ,......him: or "11.vc !OU hid UlJ olh.:"dia:a:s IX m:dical probk:na;NOT liltal UI lhis r~
Ir so. pkml: aplain;

To dr Ill!'</of111..1·
.btPu*'Cf'./liail" _.vrril"''l'ry",,_,:it111 ~·-1 ~-. ""°""'
I "rill Ur/Ol.,,,111.r rlfmisl of flll..l ilf llf}' limltlr f1lKlltr
~
Patiml"s sigiwue:, DIH.l:

RECAl.l. RF.VIEW:
I. f'li1iml'I sigallun= lllR:
2. Pllienl"ssiglnluie i::
J. f'lllimr"'S'Si.polure aoi:-:
'Illa Hlllllh flillorr is Cleated &'Id ~
8uppm;fur llllllllnPllaltl'1 WIII~
II¥'lhe UJnaNily of Iha Pacft 8clDol of DenliK)'. 8an ~
ol l• HNlh HllllurlR .....- tum MllllUll 0.-~ C... Ollilotif&

Figure 10·1. Adult health history questionnaire. (Reprinted with permission from Universityof the PacificArthur A. Dugoni School of
Dentistry, San Francisco.)

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CHAPTER 10 Physical and Psychological Evaluation 127

mld'$Namc: ---------­ 0au: ur Birdi: ----- ...,__ Dau:: ---

Addr...::---~~~--------------
PifU:ian.'$ PlllllC {MediicalDaclm'):
Ti:lqlhone: ~(----!):..__
Ti:li:phonc: ( )
_

t. w.,_-
I. ~-·--•'-Ml pmhl-1 YF.5NO
cYdapodelltllla bmplMl?••••••.•.••• m NO If. Daalr/ ••••••••••_,Moad
ll.Hmi.,_.,....._ni1alilmd-

....._m.J' .-.....ach •
···················
..... 1111 l«l

s.
ol. 0...
5.
•••• phfllcal-
II,....
llJUUl" ~=-:-==-----=:--:=
• ......••.••
cblldmlllarmedkm11111unli'
'IQ l'lU 11>.
••••••••••••• 1ES NO
ttat ...,-.,_.111.t.....,_
,... • ..._ ••••••••••. .ma-.....iilianl
,..., •.__,,. ••••••••••
WI KO
- JOO
1111.
Dooos,......child....., ••••••• .., _
•.••••-- -:--:-...,---:::::----.......,,.....-;:,-:,=--:::':::'
&. 11a,....c1m1_,.11111.~
._ •....,.-.- ·m no -.i.lo!ademml.Dllkel'••.•....•.•.•.•.... m RO
17.•••~.....,Ioli• ..,. •••.
~ ••••••••
7. 11eeo,...-dlol.._
a. (or...,,.
K-.apll&"==1i':':":==:-=======::;-
llltl)m:ollho: llilmllis,.__. a. A111ibi01ic
•• ir•D*-P .•.•.••.......•.... m NO
a. ._....., lllMl"..-*-!Ilkhanct- ••• ns NO b.Am••••••.••••••lbloool~ •••••••••••.• m NO
b. ~ ••_......_ ••••••••••••••••••• 1111 HO c......U..b•filhWmdpnmr.••••••••••.•l'lCINO
c. ~.-..... Paniruoble:..._.-".. c1. Ccrdllme••.-...... •••••••.••..•••..•....• m NO
-.uqillmfficieaCJI _,_...., JiWI
•••wk...,~ ns ~-~_::::::::::::::::::::::::::::.::~
bloodJRlmR•
••. Mllp
c. -o
Jload[] Mcdldne D Olkr a .. -
a.,-..c
f. llitos•a••••Nlli. .•.••....•••••.••••.••••
•• ninqopdbOl" ••••••••..........•.......
lD
lD
ns
l'lO
NO
NO
NO
NU
b. i-i;..,.....--.°"-,..••....•..••••
•. Dlln1iaorlilhcr••'"""'"illiuit ••.•.•.•.••.•

L ""'odlc:t-:---:--:--:-:----:-----
18.••._.••••.rape ••••••.••
~-laaeil
m NO
'1115NO

Ii. Hcp.ci61,.~orr_....._ .....•.•.•. m NO •••••....,_..,.die Molol,.t


L llilbn& •••••••••••••••.••••.•••••••••••• YES NO a. t..cl- 1DNO
j. ,..__,.........__ 1t.r..;,;;1;...,....._..,.-.,.;,.. ·
'0l5 NO
~or.....,.)111111) ns NO c.Sulii •••••••••••••.•••••••••.•••.••••••••• 115 NO
L Ndiitlll .••••••••••••••.••••••••••••••••• 'YESHO d.llmlli_......._ •••••••••m ND
•.•••••••.,..

n .....,._Ille m

=--=~~~'.".'.".~
..
L ••••••••••••••••••••••••••••••••••••••••• 'WIS NO c.Alplrln •••••••••••••••••••••••••••••••••• NO

•. "I--.rns> ••..•.................•.
l'llS NO
1'1!11
NO
r.Mr.......,--:---:--:-:--...,..,-:--:-:-----
:ipblmd •••••••••• YD NO
o. l'llllimal-.fi ..-•••••••• l!L m NO
p. 'iboer.11
..._ ••••••••••••••••••••••••••• m NO •.••••••••
.......,~~:::'.".::~~~~o:::'.".~~­
r.
~--·······························m
'I-
:!icUeClllclllcwe •••••••••••••••••••••••••
NO
DS NO
•. lhlJllUl"dild •••••••• .., ••••••• lllii<t.maid npaR
hD/herlli~orGlberloaldiig~ ..•..• 'VD NO
• -np..w.-
L AIDS .•.••.•.•••••...•.....•...••....••.
••......_..
"~-
., Cleft...,._
lD NO 11.1 •.•.•••••urdnu1~_.
WNO

••••••••••••••••••••••
•••••••••••••••••••••••••••
m
11!5 NO
DS NO
NO 1-..~
•...._L ---------
11. Hwk/oliccoa-W •••••••••••••••
m
._::=:..e:::.:,;.::r.~~NO
--
NO

L ~~·-···•····•·••·••••••·••···•DS NO
KPol:obWba" ••••• ---·-···· ml lfO
I' lleull-*'kln ••••••.•••••••••.•.••••• 'YD NO 15.O..C.lil:l•sdni!..-dadi-W ••••.•••••••••115 NO
L ~ UJNO
••••••••••••••••••••••••••••••••• a.11&u/••••alllaihwl~ ••.•••••••••••• 1D NO
•. Detdopwllll ditaliili9 ••••••••••••••••••• 'lllS NO 27.Halil:/ohehwl~-In hWl..,.-.W •• YICllNO

..,..,..... ...,..• ..-..-.-..-.-._..,us=:-:tt0= a •


•. ,.., apl&ioo ....,,.,._..,lll)aloolDbiVlrr_"",_, 1!113 NO
lib. _,,__ •• ==~l"Ci'~-.-
..-..-.-.- ..,.,.,""P'*=-----=--,=-=----
•••. Olloer. ---------- _
19. DllCIW•i-..,-or_..,.,....,._
II. DllaJjllll' llilld !me IlluBle it-WIWJ lMH :!IQ. im.,...•.•••..••••••.•.•.•.
,._chlld'•....-.
......,. w,Jmll' •••••••.•••••••••••••••••••••••
m NO
dcabdcud •.••••••••••••••.•••.••••••••••.••
1EI HO

..°"-~-...~
•••••dl: ••••••adatt ........•................. VD NO
10. bJO&"childdi •••. mudiofdooli-1 .....•.•.•..
- •.-- •..,._,-....uo.........., ....
II. •Jll'lll"clal lad .t..lUllllol liicedms_..
'ID HO
II. - JiiU ........,.=-.,
'!II NO ADOU3a!NTWDMIN:
U""dilalr.pa_,he~ W:S NO
1lD HO
11.DaaW.oht...,_Cllllifi' ...••••.•••.•..••.•.. WS HO 15. NeJiiU~ lhepilD . . . . . .. . . . . . 'ft:S ffU

To lhe bat al IDJ'knowledp. all al the ~lJI ~ 1.-.e 11ndome;t. II'IDJ'child cwa- "- • chqe
1NllWll!111 in
hil/her bealdl or 1111/her nxdlcinCI c1nnF, I will lnfimn lbe dactar at lhe next appolnmcnt wllhlllll fai.

Parent'aSignUure: ·--
MtD.ICAL HISTORY I PH•CIU.11.XAMIHmON
_
ll\U:W
·- Dale .:::::..===-=· =
Addi don

Figure 10·2. Pediatric medical history questionnaire. (From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007,
Mosby.)

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128 PART III Techniques of Regional Anesthesia in Dentistry

MetLife Historia Mmica University of the Pacific


~
-lki p;iclaa:: ;"k>.ckllkm.drl.Pa.11.•H: _
Fa:m.de~'M>:
L !\tARQl:li':C0.'11: l":'llcfRCUl.O I.A.RKSPl.UTA CORRlfCTA 1n,u..•• Rl.A.'(("Oai--iomdo'---,:-:-
1. Sf ••••• ..bl;; Cl. •••••••••••••
:!. s; ""
.,....r!
.H•••..,........,. •••••,..w•••••••••. e11a1••• ....,,,
••-,_--.,.---,••:----------------

1 Sf l'>D o.111.
Olldr>bl>.pilal'.....,.o Im wnidD.., _.,.. ••.
..,.....,. lD"' en Im 1~•••• UISUm.?
.,siSl.('111'~
.t Sf Ku o.$eC_.lr.l..:l •••• lC~ ~ mHicG'!•.•••• .pl?
F<daa••••• 611i
••• ,,.,._. m!dim: Fe:a.i.s..1 on.ci..denul:
j,,

t. Si
Sf Ku
~
~111.oculu••-- •.•• .._., •••••••
•TiNe llpirl ._.. *°4!
-...i.,..i <11d~

II. HAN'lrr ADO:


1. Si
L
9.
Ill
SI
Si
Sf
•••••
•••••
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o.. Si f';co ,•..._ ••••••.... ~.Dr. !-I. Si :-;., i,SN "-=niv.~
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16. Sf Xo 0.1/dlailm COII rm:um:a., ""-! ~1. s:: :.... •.•..'ll:ric I?
u. Si Nu o.Llillcllll:oll ;oJmlmr. ~n loi«ia? :a. Si ••••• o.Dolw • rt,illr1cn Jr,, .ni..,.ia;..,.?
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l1. Sf •••••
JI. Si Ka
B. Si •••••
• •••••••••••.••••••.•••• 6~
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·.v.. Si Moo
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••• li........,o~loo.

Si No ;.DI~?
YI.TI&.'li&U HATKNIDO: '°"
~ :....
·~~
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.••••••••
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••"- s::
Si •••••
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•••• <.'-*--=
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61. Si :Su ,;~do uoc m-tmm.! ll. Si ••••• o."."'btco••• nalqMr lip>?
6!. Sf ••••• 5 - .....:--.... ••• _....,_ mtiriio:>r. 61. :!I •••• •.••••••••••lbclrda i*ohdli.mr.
Lble •••.•.b"1C
Yl.O.O PARAMl:JKllF-'1;
r.s.. Si """ ;:BG o pUia <>lU dll~ u .....,_ p..-dlD? No. S' •••• ;.Lci~pmlil ••• ;d~ •...:
Yll. PAIL\ "JOIXJS IAIHPACllt."rllt!l1
61. Si ••••• ,;T...,.uha ..,.,.,, aip... un mE:nl""'""' u ••••••.,. 1.ccE\vqoo :"fl>
c<Gi.""~- .-iomriu?
s.i..__,_,,...r;_;,._..,.prqu., _
..,_,,..,..._..,.,._,,,,_,..,..,if •. &_...,.
--
q..,.....,.....,,,.....,....,...,,,,_,_,
1=••••••• Pllo:ii:.oc
llK\'1510.'iiSL'PLIMK.'\'TARL\:
;r111m.-:a

Fa..••
;t ••• nwlaftl•.aWtl~ftl •••••

I.AID dd. ~ f«lmi


!.l'inRdd............, 1••••••--------------
.1.Finni:.i.l.......... - --------------

n. Heallh !Isby Iscrealld .nl lllPUDc l1j de l)Mrskyd lhePacllc Set.al d Cllrtlslry.Sm Fnndsco CallonU.
SI.wort Jar lhe bnllltkrl illd cbsa1•edull of lhe ••••••• tlslaies CGllll5him Med.J'!DemI Ccn
Figure 10-3.. Spanish health history questionnaire. (Reprinted with permission from Universityof the PacificArthur A. Dugoni School
of Dentistry, San Francisco.)

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CHAPTER 10 Physical and Psychological Evaluation 129

MetLife HEALTH HISTORY INTERVIEW University af tha Pacific

PallenlNama: _

SIGNIFICANT MEDICAL FINDINGS DENTAL MANAGEMENT CONSIDERATIONS DATE

RAmlll tP.kJWlhe nllllhP.r anrl dehliR of any YFS A. ~nn C'.11Rirw1111C1.1w


responae nolEd on llEI Haalh Hiaby, plua details B. yes/rro Infectious cl8aa888
of any YES~ lo qoaetlons A lhlolfll F. C. yes/no Alargy lo medlclna
D. yes/rro Hemakiiglc, bleeclng
E. yaU'nn Mldr.ali:llls
F. yes/rro Otllar maclc8l
pttHems nnt ••• ?

Dale

n...-..~=-tr=:'=~:..~'"=-~~rmdam.C6Mna
Figure 10-4. Health history interview sheet. (Reprinted with permission from University of the Pacific Arthur A. Dugoni School of Den­
tistry, San Francisco.)

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130 PART III Techniques of Regional Anesthesia in Dentistry

MetLife MEDICAL CONSULTATION REQUEST University of the Pacific

To: Dr. _ Please complete the form below and return it to


Dr.. _

RE:

Phone# _
Date of Birth
Fax# _

Our patient has presented with the following medical problem(s}: _

The following treatment is scheduled in our clinic: _

Most patients experience the following with the above planned procedures:
bleeding: • minimal (<50ml) • significant (>50ml)
stress and anxiety: • low • medium • high

Dentist signature Date

PHYSICIAN'S RESPONSE
Please provide any information regarding the above patient's need for antibiotic prophylaxis, current cardiovascular condition,
coagulation ability, and the history and status of infectious diseases. Ordinarily, local anesthesia is obtained with 2% lidocaine,
1:100,000 epinephrine. For some surgical procedures, the epinephrine concentration may be increased to 1:50,000 for
hemostasis. The epinephrine dose NEVER exceeds 0.2 mg total.

CHECKALL THATAPPLY
• OK to PROCEED with dental treatment; NO special precautions and NO prophylactic antibiotics
are needed.
• Antibiotic prophylaxis IS required for dental treatment according to the current American Heart Association
and/or American Academy of Orthopedic Surgeons guidelines.
• Other precautions are required (please list}:. _

DO NOT proceed with treatment. (Please give reason.} _

Treatment may proceed on (Date} _


• Patient has an infectious disease:
• AIDS (please provide current lab results} • Hepatitis, type __ (acute/carrier}
• TB (PPD+/active} • Other (explain). _

Requested relevant medical and/or laboratory information is attached.

Physiciansignature Date

PATIENT CONSENT
I agree to the release of my medical information to the University of the Pacific School of Dentistry.

Patient signature Date

This Medical Consultation form is created and maintained by the University of the Pacific School of Dentistry, San Francisco, California.
Support for the translation and dissemination of the health histories comes from MetLife Dental Care.

Figure 10-5. Medical consultation form. (Reprinted with perntlssion from University of the Pacific Arthur A. Dugoni School of Dentistry,
San Francisco.)

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CHAPTER 10 Physicaland PsychologicalEvaluation 131

The health history has been translated while keeping the 4. Are You Being Treated by a Physician Now?
same question numbering sequence. Thus a dentist who For What?
speaks English and is caring for a patient who does not can Date of last medical exam?
ask the patient to complete the health history in his or her Date of last dental exam?
own language. The dentist then compares the English health Comment: Question Nos. 2, 3, and 4 seek information
history with the patient's translated health history, scanning regarding recent changesin the patient's physicalcondition.
the translated version for YES responses. When a YES is In all instances of a positive response, an in-depth dialogue
found, the dentist is able to look at the question number and history must ensue to determine the precise nature of the
match it to the question number on the English version. For change in health status, the type of surgical procedure or
example, the dentist would know that a YES response to illness, and the names of any medications the patient may
question No. 34 on the non-English version is the same as now be taking to help manage the problem.
this response to question No. 34 on the English version,
which relates to high blood pressure (HBP). For that matter, 5. Have You Had Problems With Prior Dental
a Mandarin Chinese-speaking dentist could use the multi­ Treatment?
language health history with an English-speaking patient Comment: Many adults are reluctant to verbally admit
and have the same cross-referenced information. A dentist to the dentist, hygienist,or assistant their fears about treat­
who speaks Spanish could use the multilanguage health ment, for fear of being labeleda "baby."This is especiallytrue
history with a patient who speaks French. With the uniform of young men in their late teens or early twenties; they
health history question sequence, these health history trans­ attempt to "take it like a man" or "grin and bear it" rather
lations can serve patients and dentists all around the world. than admit their fears.Becausethe most common fear men­
The health history is divided into sections related to signs tioned by dental patients is fear of injection (the "shot," in
and symptoms ("Have you experienced?"), diagnosed dis­ their words), all too often, such macho behavior results in
eases ("Do you have or have you had?"), medical treatments an episode of vasodepressor syncope. Whereas many such
(including drugs and other physiologically active com­ patients will not offer verbal admissions of fear, many of
pounds), and several other questions. these same patients will volunteer this information in
Although both long- and short-form medical history writing.
questionnaires are valuable in determining a patient's physi­
cal condition, one criticism of most available health history 6. Are You in Pain Now?
questionnaires is the absence of questions related to the Comment: The primary aim of this question is related to
patient's attitudes toward dentistry. It is recommended the need for immediate dental care. Its purpose is to deter­
therefore that one or more questions be included that relate mine what prompted the patient to seek dental care. If pain
to this all-important subject: is present, the dentist may need to treat the patient immedi­
1. Do you feel very nervous about having dental ately on an emergency basis, whereas in the more normal
treatment? situation, treatment can be delayed until future visits. This
2. Have you ever had a bad experience in the dental may affect the use of local anesthesia, in that effectivepain
office? control can be more difficult to achieve in the presence of
Question Nos. 5 and 6 on the UOP medical history ques­ infection and chronic, albeit, now acute, pain in the fearful
tionnaire address these points. patient.
Following is the UOP medical history questionnaire with
a discussion of the significance of each point.
II. HAVE YOU EXPERIENCED:
7. Chest Pain (Angina)?
I. CIRCLE APPROPRIATE ANSWER:
Comment: A history of angina (defined,in part, as chest
(Leave blank if you do not understand pain brought on by exertion and alleviatedby rest) usually
the question.) indicatesthe presence of coronary artery diseasewith atten­
1. Is Your General Health Good? dant ischemia of the myocardium. The risk factor for the
Comment: General survey questions seek patients' gen­ typicalpatient with stableangina isASA3 (AmericanSociety
eral impression of their health. Studies have demonstrated of Anesthesiologists' [ASA] physical status classification
that a YES response to this question does not necessarily system).* In the presence of dental fears, sedation is abso­
correlate with the patient's actual state ofhealth.7 lutely indicated in the angina! patient. Inhalation sedation
with N20-02 is preferred.Effectivepain control-local anes­
2. Has There Been a Change in Your Health Within the thesia with vasoconstrictor included-is absolutely indi­
Last Year? cated.Patientswith unstable or recent-onset anginarepresent
ASA4 risks.
3. Have You Been Hospitalized or Had a Serious Illness
in the Last 3 Years? *The ASA physical status classification system is discussed in detail later in
If YES, Why? this chapter.

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132 PART III Techniques of Regional Anesthesia in Dentistry

8. Swollen Ankles? coagulopathies or other bleeding disorders, injection tech­


Comment: Swollenankles (pitting edema or dependent niques with a greater incidence of positive aspiration should
edema) indicate possible heart failure (HF). However,vari­ be avoided,if possible,in favorof supraperiosteal,periodon­
coseveins,pregnancy,and renal dysfunction are other causes tal ligament (PDL), intraosseous (IO), or other techniques
of ankle edema. Healthy persons who stand on their feet for less likely to produce bleeding. Techniques that might be
long periods (e.g.,mail carriers, dental staff members) may avoided when bleeding disorders are present include the
develop ankle edema that is not life threatening, merely maxillary (V2) nerve block (high tuberosity approach), the
estheticallyunpleasing. posterior superior alveolar nerve block (PSA),the inferior
alveolar nerve block (IANB), and probably both the Gow­
9. Shortness of Breath? Gates and the Akinosi-Vaziranimandibular nerve blocks.
Comment: Although the patient may respond negatively Although the latter two techniques have relativelylow posi­
to specificquestions (questions No. 29 to No. 35 in Section tive aspiration rates,bleeding followingtheir administration
III) regarding the presence of various heart and lung disor­ is likely to occur deep in the tissues and therefore may be
ders (e.g.,angina, HF,pulmonary emphysema),clinicalsigns more difficult to manage. Modifications should be listed in
and symptoms of heart or lung disease may be evident. A the patient's chart.
positive response to this question does not alwaysindicate
that the patient suffers such a disease. To more accurately 13. Sinus Problems?
determine the patient's status before the start of dental care, Comment: Sinus problems can indicate the presence of
further evaluation is suggested. an allergy(ASA2), which should be pursued in the dialogue
history, or an upper respiratory tract infection (URI) (ASA
10. Recent Weight Loss. Fever. Night Sweats? 2), such as a common cold.The patient may experiencesome
Comment: The question refers primarily to an unex­ respiratory distresswhen placedin a supine position; distress
pected gain or loss of weight, not to intentional weight loss may also be present if a rubber dam is used. Specifictreat­
(e.g., dieting). Unexpected weight change may indicate HF, ment modifications-postponing treatment until the patient
hypothyroidism (increasedweight), hyperthyroidism,wide­ is able to breathe more comfortably,limiting the degree of
spread carcinoma, uncontrolled diabetes mellitus (weight recline in the dental chair, and foregoing use of a rubber
loss), or a number of other disorders. The presence of fever dam-are advisable.
and/or night sweatsshould be pursued to determine whether
they are innocent or perhaps cluesto the presence of a more 14. Difficulty Swallowing?
significantproblem, such as tuberculosis. Comment: Dysphagia, or the inability to swallow,can
have many causes.Beforethe start of any dental treatment,
11. Persistent Cough, Coughing Up Blood? the dentist should seek to determine the cause and severity
Comment: A positive response mandates an in-depth of the patient's complaint.
dialogue history to determine the cause of the persistent
cough or hemoptysis (blood-tinged sputum). The most 15. Diarrhea, Constipation, Blood in Stools?
common causes of hemoptysis are bronchitis and bronchi­ Comment: This is an evaluation to determine whether
ectasis,neoplasms, and tuberculosis. gastrointestinal (GI) problems are present, many of which
A chronic cough can indicate active tuberculosis or require patients to be medicated. Causes of blood in feces
other chronic respiratory disorders, such as chronic bro­ can range from benign, self-limiting events to serious life­
nchitis. Cough associated with an upper respiratory infec­ threatening disease. Common causes include anal fissures,
tion confers an ASA2 classificationon the patient, whereas aspirin-containing drugs, bleeding disorders, esophageal
chronic bronchitis in a patient who has smoked more varices,foreign body trauma, hemorrhoids, neoplasms, use
than one pack of cigarettes daily for many years may of orally administered steroids, the presence of intestinal
indicate chronic lung disease and confer on the patient an polyps, and thrombocytopenia.
ASA3 risk.
16. Frequent Vomiting, Nausea?
12. Bleeding Problems, Bruising Easily? Comment: A multitude of causescan lead to nausea and
Comment: Bleeding disorders, such as hemophilia, are vomiting. Medications, however, are among the most
associatedwith prolonged bleeding or frequent bruising and common causes of nausea and vomiting.t" Opiates, digi­
can lead to modification of certain forms of dental therapy talis, levodopa, and many cancer drugs act on the chemore­
(e.g., surgery, technique of local anesthetic administration, ceptor trigger zone in the area postrema to induce vomiting.
venipuncture) and therefore must be made known to the Drugs that frequently induce nausea include nonsteroidal
dentist before treatment is begun. anti-inflammatory drugs (NSAIDs),erythromycin, cardiac
Before a needle is inserted into the vascular soft tissues antidysrhythmics, antihypertensive drugs, diuretics, oral
of the oral cavity, it should be determined whether the antidiabetic agents, oral contraceptives,and many GI drugs,
patient is at risk of excessivebleeding. In the presence of such as sulfasalazine.3-10

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CHAPTER10 Physicaland PsychologicalEvaluation 133

GI and systemic infections, viral and bacterial, are the myasthenia gravis, vascular disturbance, and intracranial
second most common cause of nausea and vomiting. tumor.

17. Difficulty Urinating. Blood in Urine'? 23. Seizures'?


Comment: Hematuria, the presence of blood in the Comment: Seizures are common emergencies in the
urine, requires evaluationto determine the cause;it is poten­ dental environment. The most likely candidate to have a
tially indicative of urinary tract infection or obstruction. seizure is the epileptic patient. Even epilepticswho are well
controlled with antiepileptic drugs may suffer seizures in
18. Dizziness'? stressfulsituations, such as might occur in the dental office.
Comment: A positive response may indicate chronic The dentist must determine the type of seizure, the fre­
postural (orthostatic) hypotension, symptomatic hypoten­ quency of occurrence, and the drug(s) used to prevent the
sion or anemia, or transient ischemic attack (TIA), a form seizure before starting dental treatment. Treatment modifi­
of pre-stroke. In addition, patients with certain types of cation using SRPs (discussed later in this chapter) is desir­
seizuredisorders,such as the "drop attack,"may report faint­ able for patients with known seizure disorders. Sedation is
ing or dizzy spells.The dentist may be advised to perform highly recommended in the fearful epileptic dental patient
further evaluation,includinga consultationwith the patient's as a means of preventing a seizure from developing during
primary care physician.A transient ischemic attack repre­ treatment. Epilepticswhoseseizuresare under control (occur
sents an ASA3 risk, whereas chronic postural hypotension infrequently) are ASA2 risks;those with more frequent sei­
normally represents an ASA2 or 3 risk. zures represent ASA3 or 4 risk. A classicoverdose of local
anesthetic manifests as tonic-clonic seizure activity.
19. Ringing in Ears'?
Comment: Tinnitus (an auditory sensationin the absence 24. Excessive Thirst'?
of sound heard in one or both ears,such as ringing, buzzing, Comment: Polydipsia, or excessive thirst, is often­
hissing,or clicking)is a common side effectof certain drugs times seen in diabetes mellitus, diabetes insipidus, and
including salicylates,indomethacin, propranolol, levodopa, hyperparathyroidism.
aminophylline, and caffeine.It may be seen with multiple
sclerosis,tumor, and ischemic infarction. 25. Frequent Urination'?
Comment: Polyuria, or frequent urination, may be
20. Headaches? benign (too much fluid intake) or may be a symptom of
Comment: The presence of headache should be evalu­ diabetes mellitus, diabetes insipidus, Cushing syndrome, or
ated to determine the cause.Common causesinclude chronic hyperparathyroidism.
dailyheadaches,cluster headaches,migraine headaches,and
tension-type headaches. If necessary,consultation with the 26. Dry Mouth'?
patient's primary care physicianis warranted. Determine the Comment: Fearis a common causeof a dry mouth, espe­
drug(s) used by the patient to manage his or her symptoms, ciallyin the dental environment. Many other causesof xero­
because many of these agents can have an effecton the clot­ stomia are known, including Sjogren syndrome.
ting of blood that could influence choice of local anesthetic
technique (e.g., avoidance of those with a higher positive 27. Jaundice'?
aspiration rate). Comment: Jaundice,or yellownessof skin, the whites of
the eyes, and mucous membranes, is due to deposition of
21. Fainting Spells'? bile pigment resulting from an excess of bilirubin in the
Comment: Fainting (vasodepressorsyncope) is the most blood (hyperbilirubinemia). It is frequently caused by
common medical emergencyin dentistry. It is most likelyto obstruction of bile ducts, excessivedestruction of red blood
occur during administration of a local anesthetic as a result cells (hemolysis),or disturbances in the functioning of liver
of needle phobia (trypanophobia"). Prior recognition of cells.Jaundice is a sign that might be indicative of a benign
needle phobia can usuallyresult in prevention of the synco­ problem, such as a gallstone obstructing the common bile
pal episode. duct, or it may be due to pancreatic carcinoma involvingthe
opening of the common bile duct into the duodenum.
22. Blurred Vision'? Becauseamide local anesthetics undergo primary biotrans­
Comment: Blurred vision is an increasingly common formation in the liver, the presence of significant hepatic
finding as patients age. Leading causes of blurred vision dysfunction (e.g.,ASA4) may represent a relativeor absolute
and blindness include glaucoma, diabetic retinopathy, and contraindication to administration of these drugs.Articaine
macular degeneration. Double vision, or diplopia, usually HCl, which undergoes biotransformation both in the liver
results from extraocular muscle imbalance, the cause of and in the blood (plasmacholinesterase),is preferred in these
which must be sought. Common causes include damage patients because it has an elimination half-lifeof27 minutes
to third, fourth, or sixth cranial nerves secondary to (vs. 90 minutes for most other amide local anesthetics).

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134 PARTIII Techniquesof RegionalAnesthesiain Dentistry

28. Joint Pain, Stiffness'? warranted. In this situation, the dentist must consider
Comment: A history of joint pain and stiffness(arthritis) whether the patient requires supplemental 02 during treat­
may be associatedwith long-term use of salicylates{aspirin) ment. Whereas most HF patients are classifiedaccording to
or other NSAIDs,some of which may alter blood clotting. the ASAphysicalstatus classificationsystem as ASA2 (mild
Arthritic patients who are receivinglong-term corticosteroid HF without disability) or ASA3 (disabilitydevelopingwith
therapy may suffer increased risk of acute adrenal insuffi­ exertion or stress) risks,the presence of dyspnea at rest rep­
ciency,especiallythe patient who has recentlystopped taking resents an ASA4 risk. Effectivepain control is essential in
the steroid. Such patients may require a short course of the ASA2 and 3 HF patient, but care must be taken in select­
steroid therapy or a modification (increase)in corticosteroid ing the appropriate drugs and technique to prevent signifi­
dose during dental treatment, so that their body is better able cant increases in the cardiac workload. Local anesthetics
to respond to any additional stress that might be associated containing vasopressors are definitely indicated in these
with the treatment. patients because they are more likely to provide successful
Becauseof possible difficultiesin positioning the patient pain control for dental procedures compared with "plain"
comfortably,modifications may be necessary to accommo­ local anesthetics.
date the patient's physicaldisability.Most patients receiving Congenital heart lesions: An in-depth dialogue history
corticosteroids are categorized as ASA2 or 3 risk depend­ is required to determine the nature of the lesion and the
ing on the reason for the medication and the degree of degree of disability present. Patients can represent ASA 2,
disabilitypresent. Patientswith significantlydisablingarthri­ 3, or 4 risk. The dentist may recommend medical consulta­
tis are ASA 3 risks. Problems secondary to arthritis may tion, especiallyfor the pediatric patient, to judge the severity
require modification in positioning during local anesthetic of the lesion. Some dental treatments require prophylactic
injection. antibiotics.

31. Heart Murmurs'?


Comment: Heart murmurs are common, but not all
Ill. DO YOU HAVE OR HAVE YOU HAD:
murmurs are clinicallysignificant.The dentist should deter­
29. Heart Disease'? mine whether a murmur is functional (nonpathologic, or
Comment: This represents a survey question seeking to ASA 2), whether clinical signs and symptoms of valvular
detect the presence of any and all types of heart disease.In stenosis or regurgitation are present (ASA 3 or 4), and
the presence of a YES answer, the dentist must seek more whether antibiotic prophylaxisis warranted. A major clinical
specificdetailed information as to the nature and severityof symptom of a significant(organic) murmur is undue fatigue.
the problem and a list of any medications taken by the Table 10-1 provides guidelines for antibiotic prophylaxis
patient to manage the condition. Because many forms of (most recently revised in 2007).15 Box 10-1 categorizes
heart diseaseare exacerbated in the presence of stress, con­ cardiacproblems as to their requirements for antibiotic pro­
sideration of the SRPbecomes increasinglyimportant. phylaxis, and Box 10-2 addresses prophylaxis and dental
procedures specifically.Asnoted in the Guidelines,antibiotic
30. Heart Attack. Heart Defects'? prophylaxis is NOT indicated for the administration of
Comment: Heart attack is the lay term for myocardial routine dental injection techniques through noninfected
infarction (MI). The dentist must determine the time that tissues. Guidelines for antibiotic prophylaxis in orthopedic
has elapsed since the patient sufferedthe Ml, the severityof patients with total joint replacements were published ini­
the MI, and the degree of residual myocardial damage to tially in 200316 and were last revised in 2010.17
decide whether treatment modifications are indicated. Elec­
tive dental care traditionally has been withheld for the first 32. Rheumatic Fever?
6 months after an MI,12 although recent evidence demon­ Comment: A history of rheumatic fever should prompt
strates that many patients are able to tolerate stress in as few the dentist to perform an in-depth dialogue history for the
as 3 to 4 weeks after experiencing an Ml.13'14 Most post-MI presence of rheumatic heart disease (RHD). In the presence
patients are considered to be ASA3 risks 6 months or more of RHD,antibiotic prophylaxismay be indicated as a means
after the event; however,a patient who has experienced an of minimizing the risk of developing subacute bacterial
MI within 6 months before the planned dental treatment endocarditis (SBE).Depending on the severityof the disease
should be considered an ASA4 risk until medical consulta­ and the presenceof a disability,RHD patients can be an ASA
tion with his or her cardiologist is obtained. When little or 2, 3, or 4 risk. Additional treatment modifications may be
no residualdamageto the myocardium is present,the patient advisable.
may be considered an ASA2 risk after 6 months.
Heart failure: The degree of heart failure (weakness of 33. Stroke, Hardening of Arteries'?
the "pump") present must be assessedthrough the dialogue Comment: The dentist must paycloseattention to stroke,
history.When a patient has a more serious condition, such cerebrovascularaccident (CVA),or "brain attack" (the term
as congestive heart failure (CHF) or dyspnea {labored increasinglyused to confer on the laypublic and health care
breathing) at rest, specific treatment modifications are professionalsthe urgencyneeded in prompt management of

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CHAPTER 10 Physical and Psychological Evaluation 135

TABLE 10-1
Antibiotic Prophylaxis 2007*
Situation Agent Adults Children
Oral Amoxicillin 2g 50 mg/kg
Unable to take oral medication Ampicillin or 2 gIM or IVt 50 mg/kg IM or IV
Cefazolinor ceftriaxone 1 gIM or IV 50 mg/kg IM or IV
Allergicto penicillins or ampicillin Cephalexin:j:§ 2g 50 mg/kg
Oral or
Clindamycin 600mg 20 mg/kg
or
Azithromycin or clarithromycin 500mg 15 mg/kg
Allergicto penicillins or ampicillin Cefazolinor ceftriaxone§ 1 gIM or IV 50 mg/kg IM or IV
and unable to take oral or
medication Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
From Wilson W, Taubert KA,Gewitz M, et al: Prevention of infectiveendocarditis: guidelinesfrom the American Heart Association:a guideline from the
American Heart AssociationRheumatic Fever,Endocarditis, and KawasakiDiseaseCommittee, Council on CardiovascularDiseasein the Young,and the
Council on Clinical Cardiology,Council on CardiovascularSurgery and Anesthesia,and the Quality of Care and Outcomes ResearchInterdisciplinary
Working Group, Circulation 116:1736--1754,2007.
*Regimen:single dose 30 to 60 minutes before procedure.
tIM, Intramuscular; N, intravenous.
:j:Orother first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
§Cephalosporins should not be used in an individual with a history of anaphylaxis,angioedema, or urticaria with penicillins or ampicillin.

BOX 10-1 Cardiac Conditions Associated With the BOX 10-2 Dental Procedures for Which Endocarditis
Highest Risk of Adverse Outcome from Prophylaxis Is Recommended for Patients
Endocarditis for Which Prophylaxis With
All dental procedures that involvemanipulation of gingi­
Dental Procedures Is Recommended
val tissue or the periapical region of teeth or perforation
• Prosthetic cardiac valve of the oral mucosa.*
• Previous infectiveendocarditis
*The followingprocedures and events do not need prophylaxis:routine
• Congenital heart disease (CHD)* anesthetic injections through noninfected tissue, taking of dental
• Unrepaired cyanotic CHD, including palliative radiographs, placement of removable prosthodontic or orthodontic
shunts and conduits appliances,adjustment of orthodontic appliances,placement of
• Completelyrepaired congenital heart defect with orthodontic brackets, shedding of deciduous teeth, and bleeding from
trauma to the lips or oral mucosa.
prosthetic material or device,whether placed by
surgery or by catheter intervention, during the first
6 mo after the proceduret
• Repaired CHD with residual defectsat the site or presence of transient cerebralischemia (TCI), a precursor to
adjacent to the site of a prosthetic patch or CVA;TCI represents an ASA3 risk. The post-CVApatient is
prosthetic device (which inhibits endothelialization) an ASA 4 risk within 6 months of the CVA,becoming an
• Cardiac transplantation recipients who develop ASA3 risk 6 or more months after the incident (if the recov­
cardiac valvulopathy ery is uneventful). In rare cases,the post-CVApatient can be
an ASA2 risk.
tProphylaxisis recommended because endothelialization of prosthetic
material occurs within 6 mo after the procedure.
*Exceptfor the conditions listed previously,antibiotic prophylaxisis no 34. High Blood Pressure?
longer recommended for any form of CHD. Comment: Elevatedblood pressure (BP) measurements
are frequently encountered in the dental environment sec­
ondary to the added stressthat many patients associatewith
the victim of a CVA).A patient who has suffered a CVAis a visit to the dental office.With a history of HBP,the dentist
at greater risk of suffering another CVAor a seizure should must determine the drugs the patient is taking, the potential
he or she become hypoxic. The importance of effective side effectsof those medications, and any possible interac­
pain control, through administration of local anesthetic tions with other drugs that might be used during dental
solutions with vasopressors,cannot be overstated.Epineph­ treatment. Guidelines for clinical evaluation of risk (ASA
rine concentrations should be minimized (e.g., 1:200,000) categories) based on adult BP values are presented later in
but this agent should be included as it increases anesthetic this chapter. The SRP is a significant factor in minimizing
effectiveness.The dentist should be especiallysensitiveto the further elevation in BP during treatment.

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136 PART III Techniques of Regional Anesthesia in Dentistry

35. Asthma, Tuberculosis (TB), Emphysema, Other administration are selected for the patient with significant
Lung Disease? hepatic dysfunction. In general, local anesthetics and vaso­
Comment: Determining the nature and severity of res­ pressors are indicated for use, with consideration of mini­
piratory problems is an essential part of patient evaluation. mizing the dose in patients with severe hepatic dysfunction
Many acute problems developing in the dental environment (e.g., ASA 4).
are stress related, increasing the workload of the cardio­
vascular system and the 02 requirements of many tissues 37. Stomach Problems, Ulcers?
and organs in the body. The presence of severe respiratory Comment: The presence of stomach or intestinal ulcers
disease can greatly influence the planned dental treatment may be indicative of acute or chronic anxiety and the pos­
and the choice of drugs and technique if sedation is required. sible use of medications such as tranquilizers, H 1-inhibitors,
Asthma (bronchospasm) is marked by a partial obstruc­ and antacids. Knowledge of which drugs are taken is impor­
tion of the lower airway. The dentist must determine the tant before additional drugs are administered in the dental
nature of the asthma (intrinsic [allergic] vs. extrinsic [nonal­ office. A number of H 1-inhibitors are now over-the-counter
lergic]), the frequency of acute episodes, causal factors, the (OTC) drugs. Because many patients do not consider OTC
method of management of acute episodes, and drugs the drugs "real" medications, the dentist must specifically ques­
patient may be taking to minimize the occurrence of acute tion the patient about them. The presence of ulcers does not
episodes. Stress is a common precipitating factor in acute itself represent increased risk during treatment. In the
asthmatic episodes. The well-controlled asthmatic patient absence of additional medical problems, the patient may
represents an ASA 2 risk, whereas the well-controlled but represent an ASA 1 or 2 risk.
stress-induced asthmatic patient is an ASA 3 risk. Patients
whose acute episodes are frequent and/or difficult to termi­ 38. Allergies to: Drugs, Foods, Medications, Latex?
nate (requiring hospitalization [status asthmaticus]) are Comment: The dentist must evaluate a patient's allergies
ASA 3 or 4 risk. thoroughly before administering dental treatment or drugs.
With a history of tuberculosis, the dentist must first deter­ The importance of this question and its full evaluation
mine whether the disease is active or arrested. (Arrested cannot be overstated. A complete and vigorous dialogue
tuberculosis represents an ASA 2 risk.) Medical consultation history must be undertaken before any dental treatment is
and dental treatment modification are recommended when begun, especially when a presumed or documented history
such information is not easily determined. of drug allergy is present. Adverse drug reactions (ADRs)
Emphysema is a form of chronic obstructive pulmonary are not uncommon. Many, if not most, ADRs are labeled
disease (COPD), also called chronic obstructive lung disease as "allergy" by the patient and also on occasion by his or
(COLD). The emphysematous patient has a decreased respi­ her health care professional. However, despite the great fre­
ratory reserve from which to draw if cells of the body require quency with which allergy is reported, true documented
additional 02, which they do during stress. Supplemental 02 and reproducible allergic drug reactions are relatively rare.
therapy during dental treatment is recommended in severe A recent review of food allergy revealed 30% self-reporting
cases of emphysema; however, the severely emphysematous of "food allergy" by the studied population, when the reality
(ASA 3 and 4) patient should not receive more than 3 L of is that true food allergy is seen in 8% of children and 5%
02 per minute.18 This flow restriction helps to ensure that of adults."
the dentist does not eliminate the hypoxic drive, which is the All ADRs must be evaluated thoroughly, especially when
emphysematous patient's primary stimulus for breathing. the dentist plans to administer or prescribe closely related
The emphysematous patient is an ASA 2, 3, or 4 risk, depend­ medications for the patient during dental treatment. Alleged
ing on the degree of disability. "allergy to Novocaine" is frequently reported.
The incidence of true, documented, reproducible allergy
36. Hepatitis, Other Liver Disease? to the amide local anesthetics is virtually nil. 21·22However,
Comment: Liver diseases may be transmissible (hepatitis reports of alleged allergy to local anesthetics is common.P'"
A and B) or may indicate the presence of hepatic dysfunc­ Thorough investigation of the alleged allergy is essential
tion. A history of blood transfusion or of past or present if the patient is not to be assigned the label of "allergic
drug addiction should alert the dentist to a probable increase to all -caine drugs:' thereby precluding dental (and surgical)
in the risk of hepatic dysfunction. (Hepatic dysfunction is care in a normal manner. Avoidance of dental care or receipt
a common finding in the parenteral drug abuse patient.) of care under general anesthesia is the alternative in these
Hepatitis C is responsible for more than 90% of cases of cases.
posttransfusion hepatitis, but only 4% of cases are attri­ Reports of allergy to "epinephrine" or "adrenaline" also
butable to blood transfusion; up to 50% of cases are related must be carefully evaluated. Most often, such reports prove
to N drug use. Incubation of hepatitis C averages 6 to 7 to be simply an exaggerated physiologic response by the
weeks. The clinical illness is mild, usually asymptomatic, and patient to the injected epinephrine or, more commonly, to
characterized by a high rate (>50%) of chronic hepatitis.19 endogenous catecholamine release in response to the act of
Because most drugs undergo biotransformation in the liver, receiving the injection (the "adrenal squeeze," as a colleague
care must be taken when specific drugs and techniques of called it recently).

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CHAPTER 10 Physicaland PsychologicalEvaluation 137

Two essential questions that must be asked in all instances scopolamine, and glycopyrrolate, are contraindicated in
of alleged allergy are these: (1) Describe your reaction, and patients with acute narrow angle glaucoma because these
(2) How was it managed? drugs produce an increase in intraocular pressure. Patients
The presence of allergy alone represents an ASA 2 risk. with glaucoma are usuallyASA2 risks. There is no contra­
No emergency situation is as frightening to health care indication to local anestheticadministration with or without
professionals as the acute, systemic allergic reaction known vasopressors.
as anaphylaxis. Prevention of this life-threatening situation
is more gratifying than treatment of anaphylaxis once it 44. Skin Diseases?
develops. Comment: Skin represents an elastic, rugged, self­
Investigation into a patient's report of "allergy to local regenerating,protective coveringfor the body. The skin also
anesthesia"is so important that it is discussed in depth in represents our primary physical presentation to the world
Chapter 18. and as such displays a myriad of clinical signs of disease
processes,including allergyand cardiac,respiratory,hepatic,
39. Family History of Diabetes. Heart Problems. and endocrine disorders.25
Tumors?
Comment: Knowledge of family history can assist in 45. Anemia?
determining the presenceof a number of disorders that have Comment: Anemia is a relativelycommon adult ailment,
some hereditary component. especially among young adult women (iron deficiency
anemia). The dentist must determine the type of anemia
40. Acquired Immunodeficiency Syndrome (AIDS}? present. The ability of the blood to carry 02 or to giveup 02
Comment: Patients who have a positive test result for to other cellsis decreased in anemic patients. This decrease
human immunodeficiencyvirus (HN) are representativeof can become significantduring procedures in which hypoxia
every area of the population. The usual barrier techniques is likely to develop. There is no contraindication to local
should be employed to minimize risk of cross-infection for anesthetic administration with or without vasopressors.
both patient and staff members. Patients who are HN posi­ Sickle cell anemia is seen exclusivelyin black patients.
tive are considered ASA2, 3, 4, or 5 risk depending on the Periods of unusual stress or of 02 deficiency(hypoxia) may
current status of their infection. precipitate sicklecell crisis.Administration of supplemental
Proper care and handling of the local anesthetic syringe/ 02 during treatment is strongly recommended for patients
needle must be observed, as in all situations, to avoid acci­ with sicklecelldisease.Personswith sicklecelltrait represent
dental needle-stick injury. ASA2 risk, whereas those with sicklecell disease are 2 or 3
risks.
41. Tumors. Cancer? In addition, congenital or idiopathic methemoglobin­
Comment: The presence or prior existence of cancer emia, although rare, represents a relativecontraindication to
of the head or neck may require specific modification of administration of the amide local anesthetic prilocaine.26
dental therapy. Irradiated tissues have decreased resistance
to infection, diminished vascularity, and reduced healing 46. VD (Syphilis or Gonorrhea}?
capacity. No specific contraindication exists to admini­
stration of drugs for the management of pain or anxiety in 47. Herpes?
these patients; however,techniques of local anesthetic drug Comment: When treating patients with sexually trans­
administration may, on rare occasion,be contraindicated if mitted diseases (STDs), dentists and staff members are at
the tissues in the area of deposition have been irradiated. risk of infection. In the presence of oral lesions, elective
Many persons with cancer may be receiving long-term dental caremight be postponed. Standardbarrier techniques,
therapy with CNS depressants, such as antianxiety drugs, such as protective gloves, eyeglasses,and masks, provide
hypnotics, and opioids. Consultation with the patient's operators with a degree of (but not total) protection. Such
oncologistis recommended before dental treatment isbegun. patients usuallyrepresent ASA2 and 3 risks but may be 4 or
A past or current history of cancer does not necessarily 5 risks in extreme situations.
increaseASArisk status.However,patients who are cachectic
or hospitalized or are in poor physicalcondition may repre­ 48. Kidney. Bladder Disease?
sent ASA4 or 5 risk. Comment: The dentist should evaluate the nature of
the renal disorder. Treatment modifications including anti­
42. Arthritis. Rheumatism? biotic prophylaxis may be appropriate for several chronic
Comment: See Comment for question No. 28. forms of renal disease. Functionally anephric patients are
ASA 3 or 4 risks, whereas patients with most other forms
43. Eye Disease? of renal dysfunction may be ASA 2 or 3 risks. Box 10-3
Comment: For patients with glaucoma, the need to shows a sample dental referral letter for a patient on long­
administer a drug that diminishes salivarygland secretions term hemodialysistreatment as the result of chronic kidney
will haveto be addressed.Anticholinergics,such as atropine, disease.

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138 PARTIII Techniquesof RegionalAnesthesiain Dentistry

severity,and degree of control of his or her diabetic con­


BOX 10-3 Hemodialysis Letter dition. A patient with type 1 (insulin-dependent diabetes
Dear Doctor: mellitus, or IDDM) or type 2 (non-insulin-dependent dia­
The patient who bears this note is undergoing long­ betes mellitus, or NIDDM) diabetes mellitus is rarely at
term chronic hemodialysistreatment because of chronic great risk from dental care or commonly administered
kidney disease. In providing dental care to this patient, dental drugs (e.g.,local anesthetics,epinephrine, antibiotics,
please observe the followingprecautions: CNS depressants). The NIDDM patient is usually an ASA
1. Dental treatment is most safelydone 1 day after the 2 risk; the well-controlled IDDM patient, an ASA 3 risk;
last dialysistreatment or at least 8 hours thereafter. and the poorly controlled IDDM patient, an ASA 3 or 4
Residualheparin may make hemostasis difficult. risk.
(Some patients are on long-term anticoagulant The greatest concerns during dental treatment relate to
therapy.) the possible effectsof the dental care on subsequent eating
2. We are concerned about bacteremic seeding of the and development of hypoglycemia (low blood sugar).
arteriovenous shunt devicesand heart valves.We Patients leavinga dental officewith residual soft tissue anes­
recommend prophylactic antibiotics before and after thesia, especiallyin the mandible (e.g.,tongue, lips), usually
dental treatment. Antibiotic selection and dosage defer eating until sensation returns, a period potentially of
can be tricky in renal failure. 5 (lidocaine, mepivacaine, articaine, prilocaine with vaso­
We recommend 3 g of amoxicillin 1 hour before the constrictor) or more (up to 12) hours (bupivacaine with
procedure and 1.5 g 6 hours later.For patients with peni­ vasoconstrictor). Diabetic patients have to modify their
cillin allergies, 1 g of erythromycin 1 hour before the insulin doses if they do not maintain normal eating habits.
procedure and 500 mg 6 hours later is recommended. Administration of the local anesthetic reversal agent, phen­
Sincerely, tolamine mesylate,at the conclusion of dental treatment can
significantly minimize the duration of residual soft tissue
anesthesia.27.28

49. Thyroid, Adrenal Disease?


IV. DO YOU HAVE OR HAVE YOU HAD:
Comment: The clinical presence of thyroid or adrenal 51. Psychiatric Care?
glanddysfunction-hyperfunction or hypofunction---should Comment: The dentist should be aware of any nervous­
prompt the dentist to use caution in administering certain ness (in general or specifically related to dentistry) or
drug groups (e.g., epinephrine to hyperthyroid patients, history of psychiatric care before treating the patient. Such
CNSdepressantsto hypothyroid patients). In most instances, patients may be receiving a number of drugs to manage
however,the patient has previouslyseen a physicianand has their disorders that might interact with drugs the dentist
undergone treatment for thyroid disorder by the time he or uses to control pain and anxiety (Table 10-2). Medical
she seeks dental treatment. In this case,the patient is likely consultation should be considered in such cases.Extremely
to be in a euthyroid state (normal blood levels of thyroid fearful patients are ASA2 risks, whereas patients receiving
hormone) because of surgical intervention, irradiation, or psychiatric care and drug therapy represent ASA2 or 3 risk.
drug therapy. The euthyroid state represents an ASA2 risk,
whereas clinicalsigns and symptoms of hyperthyroidism or 52. Radiation Treatments?
hypothyroidism represent ASA3 or, in rare instances,ASA4
risk. Patients who are clinicallyhyperthyroid are more likely 53. Chemotherapy?
to hyper-respond to "usual" doses of epinephrine (e.g., Comment: Therapies for cancer.See Comment for ques­
develop tachycardia, have elevated blood pressure). Vital tion No. 41.
signs should be monitored preoperatively,perioperatively,
and postoperativelyin these situations. 54. Prosthetic Heart Valve?
Patients with hypofunctioning adrenal cortices have Comment: Patients with prosthetic (artificial) heart
Addison diseaseand receivedaily replacement doses of glu­ valves are no longer uncommon. The dentist's primary
cocorticosteroids.In stressful situations, their body may be concern is to determine whether antibiotic prophylaxis is
unable to respond appropriately, leading to loss of con­ required. Antibiotic prophylactic protocols were presented
sciousness.Hypersecretion of cortisone, Cushing syndrome, earlier in this chapter," The dentist should be advised to
rarely results in an acute life-threatening situation. Consid­ consult with the patient's physician(e.g.,the cardiologist,the
eration of sedation, in the presence of dental anxiety, is cardiothoracicsurgeon) beforeprovidingtreatment. Patients
recommended. with prosthetic heart valvesusuallyrepresentASA2 or 3 risk.
Administration of local anesthetic drugs and vasopressorsis
50. Diabetes? indicated for these patients. Antibiotic prophylaxis is not
Comment: A patient who responds positively to this indicated for the administration of routine dental injection
question requires further inquiry to determine the type, techniques through noninfected tissues."

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CHAPTER 10 Physicaland PsychologicalEvaluation 139

TABLE 10-2
Dental Drug Interactions With Local Anesthetics and Vasopressors*
Dental Drug Interacting Drug Consideration Action
Local anesthetics Cimetidine, P-adrenergicblocker Hepatic metabolism of amide LA Use LAscautiously,especially
(LAs) (propranolol) may be depressed repeat dosages
Antidysrhythmics (mexiletine,tocainide) Additive CNS,CVSdepression Use LAscautiously-keep
dose as low as possibleto
achieveanesthesia
CNS depressants:alcohol, antidepressants, Possibleadditive or supra-additive Consider limiting maximum
antihistamines, benzodiazepines, CNS,respiratory depression dose of LAs,especiallywith
antipsychotics,centrally acting opioids
antihypertensives,muscle relaxants,
other LAs,opioids
Cholinesteraseinhibitors: antimyasthenics, Antimyasthenic drug dosage may Physicianconsultation
antiglaucoma drugs require adjustment because LA
inhibits neuromuscular
transmission
Vasoconstrictors; a-Adrenergic blockers Possiblehypotensiveresponse Use vasoconstrictor
epinephrine (phenoxybenzamine,prazosin); followinglarge dose of cautiously-as low a dose as
antipsychotics (haloperidol, epinephrine possible
entacapone)
Catecholamine-0-methyltransferase May enhance systemicactions of Use vasoconstrictor
inhibitors (tolcapone, entacapone) vasoconstrictors cautiously-as low a dose as
possible
CNS stimulants (amphetamine, Effectsof stimulant or Use vasoconstrictor
methylphenidate); ergot derivatives vasoconstrictor may occur cautiously-as low a dose as
(dihydroergotamine,methysergide) possible
Cocaine Effectsof vasoconstrictors;can result Avoiduse of vasoconstrictor
in cardiac arrest in patient under influence
of cocaine
Digitalisglycosides(digoxin,digitoxin) Risk of cardiac dysrhythmias Physicianconsultation
Levodopa,thyroid hormones Largedoses of either (beyond Use vasoconstrictor
(levothyroxine,liothyronine) replacement doses) may risk cautiously-as low a dose as
cardiac toxicity possible
Tricyclicantidepressants (amitriptyline, May enhance systemiceffectsof Avoiduse of levonordefrin or
doxepin, imipramine) vasoconstrictor norepinephrine; use
epinephrine cautiously-as
low a dose as possible
NonselectiveP-blockers (propranolol, May lead to hypertensiveresponses, Monitor BP after initial LA
nadolol) especiallyto epinephrine injection
From Ciancio SG:ADA/PDRguide to dental therapeutics, ed 5, Chicago,2010,American Dental Association.
BP,Blood pressure; CNS, central nervous system;CVS, cardiovascularsystem.
*Drug-drug interactions of greater clinicalsignificanceare emboldened for emphasis.

55. Artificial Joint?


Comment: More than 1,000,000total joint arthroplasties who may be at increased risk for the development of hema­
are performed annually in the United States.17 An expert togenous total joint infection (Table 10-3).16
panel of dentists,orthopedic surgeons,and infectiousdisease
specialists convened by the American Dental Association 56. Hospitalization?
(ADA)and the AmericanAcademyof Orthopaedic Surgeons
performed a thorough reviewof availabledata to determine 57. Blood Transfusions?
the need for antibiotic prophylaxisto prevent hematogenous
prosthetic joint infection in dental patients who have under­ 58. Surgeries?
gone total joint arthroplasty.The panel concluded that anti­ Comment: Determine the reason for hospitalization,the
biotic prophylaxis is not recommended for dental patients duration of the hospital stay,and anymedicationsprescribed
with pins, plates, and screws,or for those who have under­ that the patient may currently be taking.
gone total joint replacement. However,dentists should con­ Determine the reason for the blood transfusion (e.g.,pro­
sider antibiotic premedication in a small number of patients longed bleeding, accident, type of surgery).

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140 PARTIII Techniquesof RegionalAnesthesiain Dentistry

when inhalation sedation (N20-02) is employed because


TABLE 10-3 any leakageof gasesfrom the nasal hood is likelyto irritate
Orthopedic Prophylaxis the eyes.
Patient Type Condition Placing Patient at Risk
All patients during first NA
V. ARE YOU TAKING:
2 years following
joint replacement 61. Recreational Drugs?
Immunocompromised/ Inflammatory arthropathies such as Comment: Although most patients will not admit to the
immunosuppressed rheumatoid arthritis, systemiclupus use of recreational drugs, it is important to ask the question.
patients erythematosus This becomes particularly important when the dentist is
Patients with Previous prosthetic joint infection consideringthe use of CNS-depressantdrugs for sedation or
comorbidities* Malnourishment
local anesthetics with or without a vasoconstrictor, such as
Hemophilia
HN infection
epinephrine.
Insulin-dependent (type 1) diabetes
Malignancy 62. Drugs, Medications, Over-the-Counter Medicines
(Including Aspirin), Natural Remedies?
Data from American Dental Association,American Academyof
Orthopedic Surgeons:Antibiotic prophylaxisfor dental patients with total
Comment: Because many patients make a distinction
joint replacements, J Am Dent Assoc 134:895-898,2003. between the terms drug and medication, questionnaires
Hiv; Human immunodeficiencyvirus; NA,not applicable. should use both terms to determine what drugs (pharma­
*Patientspotentially at increased risk of experiencinghematogenous total ceutically active substances) a patient has taken. Unfortu­
joint infection. nately, in today's world, the term drug often connotes the
illicit use of medications (e.g., opioids). In the minds of
many patients, people "do" drugs but "take" medications
Determine the nature (elective,emergency) and type of for the management of medical conditions. Additionally,
surgery (cosmetic,GI,cardiac,etc.) and the patient's physical natural remedies contain active substances, some of which
status at the present time. may interact with drugs commonly used in dentistry.29•30
The dentist must be aware of all medications and drugs
59. Pacemaker? that their patients take to control and treat medical disor­
Comment: Cardiac pacemakers are implanted beneath ders. Frequently,patients take medications without knowing
the skin of the upper chest or the abdomen with pacing the condition the medications are designed to treat; many
wires extending into the myocardium. The most frequent patients do not even know the names of drugs that they are
indication for the use of a pacemaker is the presence of taking. It becomes important therefore for dentists to have
a clinicallysignificant dysrhythmia. Fixed-rate pacemakers available one or more means of identifying these medica­
provide a regular, continuous heart rate regardless of the tions and of determining their indications, side effects,and
heart's inherent rhythm, whereas the more commonly used potential drug interactions. Many excellent sources are
demand pacemakeris activatedonlywhen the rhythm of the available,including online services,such as MD Consult,*
heart falls into an abnormal range. Although there is little Lexi-Comp,' and Epocrates.*The Physicians' Desk Reference
indication for antibiotic administration in these patients, (PDR),31 both in hard copy and online, offers a picture
medical consultation is suggestedbefore the start of treat­ section that aids in identification of commonly prescribed
ment to obtain the specificrecommendations of the patient's drugs. The PDR also offersthe Physicians' Desk Reference for
physician. The patient with a pacemaker is commonly an Herbal Medicines.31 The ADA Guide to Dental Therapeutics
ASA 2 or 3 risk during dental treatment. is another valuable reference to those drugs commonly
In recent years, persons who represent a significant risk employed in dentistry and to the medications most often
of sudden unexpected death (e.g., cardiac arrest) as a result prescribed by physicians.Potential complications and drug
of electrical instability of the myocardium (e.g.,ventricular interactions are stressed.31"
fibrillation) have had implantable cardioverter-defibrillators Knowledge of the drugs and medications patients are
(ICDs) placed below the skin of their chest.Medicalconsul­ taking permits dentists to identify medical disorders, possi­
tation is strongly recommended for these patients. ble side effects-some of which may be of significance
in dental treatment (e.g., postural hypotension)-and pos­
60. Contact Lenses? sible interactions between those medications and the drugs
Comment: Contactlensesarecommonlyworn bypersons administered during dental treatment (see Table 10-2).
with visual disturbances. Dental considerations for patients
with contact lenses include removal of the lenses during 63. Tobacco in Any Form?
administration of any sedation technique. Sedated patients
may not closetheir eyesas frequently as unsedated patients, *MD Consult: www.mdconsult.com.
thereby increasing the likelihood of irritating the sclera tLexi-Comp: www.lexi.com.
and cornea of the eye. This is particularly recommended :j:Epocrates:www.epocrates.com.

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CHAPTER10 Physicaland PsychologicalEvaluation 141

64. Alcohol? (or the parent or guardian if the patient is a minor or is not
Comment: Chronic use of tobacco and/or alcohol over legallycompetent) and the dentist who reviewsthe history.
extended periods can lead to the development of potentially This in effectbecomesa contract obligingthe patient, parent,
life-threateningproblems including neoplasms,hepatic dys­ or guardian to report any changes in the patient's health or
function, and, in women, complications during pregnancy. medications. Brady and Martinoff' demonstrated that a
patient's analysisof personal health frequentlyis overlyopti­
mistic, and that pertinent health matters sometimes are not
VI. WOMEN ONLY: immediately reported.
65. Are You or Could You Be Pregnant or Nursing? The medical history questionnaire should be updated on
a regular basis, approximately every 3 to 6 months or after
66. Taking Birth Control Pills? any prolonged lapse in treatment. In most instances, the
Comment: Pregnancy represents a relativecontraindica­ entire medical history questionnaire need not be redone.
tion to extensiveelectivedental care, particularly during the The dentist or dental hygienist need only ask the following
first trimester. Consultation with the patient's obstetrician­ questions:
gynecologist(OBGYN)is recommended before the start of 1. Haveyou experiencedany change in your general health
any dental treatment. Administration of local anesthetics since your last dental visit?
with or without epinephrine is acceptableduring pregnancy. 2. Are you now under the care of a physician?If so, what
Food and Drug Administration (FDA)pregnancy categories is the condition being treated?
are presented in Box 10-4, and known fetal effectsof local 3. Are you currently taking any drugs, medications, or
anesthetics and vasopressorsare presented in Table 10-4. over-the-counter products?
If any of these questions elicits a positive response, a
detailed dialogue history should follow. For example,