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1301 Smile Way
York, PA 17404
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Clinical Education
Assessing Anesthetic Options for Nonsurgical Periodontal Therapy
Course Description:
To deliver optimal patient care, pain management is an essential component of periodontal therapy
procedures. Supported by science, this course will provide the dental professional with the information
necessary to make an anesthetic choice based on each patient’s needs.
Course Objectives:
Upon completion of the course the participant will be able to:
 Identify medical considerations for local anesthesia
 Review neurophysiology of drug interactions
 Discuss pharmacodynamics of local anesthetics
 Evaluate local anesthetic drugs to include; topical, injectable and non- injectable drugs
 Identify dental innervations techniques
 Identify local anesthetic complications
 Review signs and symptoms of anesthetic overdose
 Preview new anesthetic technologies
COURSE OUTLINE
1. Assessment Considerations
 Medical history challenges
 Pain management concerns
 Pregnancy
 Fear
 Multiple medications
 Undiagnosed and undisclosed medical conditions
 Cardiovascular problems
ASA Physical Status Classification
 ASA I
o Normal, health patient
 ASA II
o Mild, systemic disease
 ASA III
o Severe systemic disease, not incapacitating – may need alterations to LA
 ASA IV Severe systemic disease, constant threat to life – may experience adverse events to LA,
modifications necessary
 ASA V
o Moribund, imminent death – dental care is contraindicated
ASA Medical Component Patient Assessment Evaluation
 Pre-anesthetic evaluation of patient
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 Prescription of the anesthetic plan
 Personal participation in technical aspects of regional anesthetic
 Remain physically available for treatment of emergencies
 Provide indicated post-anesthetic care
Definition of Pain
Unpleasant sensation necessary for survival
 Informs body of potentially dangerous changes
 Have a protective function
 Triggers reflex reaction to retract from painful stimulus
 If ignored could cause irreparable damage
Classifications of Pain
 Nociceptive pain-sensory receptors that detect injury
 Neuropathic pain - nerve injury or dysfunction of the sensory nerves
 Pain disorders associated with psychogenic factors
Considerations of the Fearful Patient
 Fear as a barrier
 Assessing and addressing strategies to manage fear
 Common psychogenic adverse events – hyperventilation, syncopy
Protocol for Stressful Patients
 Premedicate prior to appointment
 Short morning appointments
 Minimize waiting time and monitor vital signs
 Administer adequate pain control
 Post- operative pain and anxiety control
 Follow up treatment
2. Pregnancy Modifications and Considerations
Pregnancy Guidelines for Perinatal Care Dental Anesthetic Drug Categories
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Category B: No evidence of risk in humans; either animal studies show risk
Category C: Human studies are lacking and animal studies are either positive for fetal risk or lacking
as well
Category D: Positive evidence of risk
3. Multiple Medications and Potential Drug Interactions
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Medical and Dental History
Patient’s medical status
Medications (Rx and OTC)
Dietary and Herbal Supplements
Previous history with dental anesthetics
Street Drugs – Methamphetamines, alcohol, marijuana
PIL-Product/Patient Information Leaflet
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4. Cardiovascular Concerns
Cardiovascular Concerns
 ADA & AHA Guidelines for prevention of Infective Endocarditis
 Cardiovascular Accidents (CVA): Absolute contraindication within first 6 months
 Transient Ischemic Attacks (TIA): Absolute contraindications within first 6 months
 Myocardial Infarct
 Hypertension
5. Metabolic Considerations
Metabolic Concerns
 Liver disease: Relative contraindication
 Kidney disease: Relative contraindication
 Uncontrolled diabetes: Relative contraindication
 Uncontrolled hyperthyroidism: Absolute contraindication
 Methemoglobinemia
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6. Undiagnosed and Undisclosed Medical Conditions
Undiagnosed and Undisclosed Medical Conditions
 Language barriers
 Hearing impaired
 Special needs
 Cultural barriers
 Informed consent
7. Pharmacodynamics of Local Anesthetics
Block nerve impulses
 Blocks sodium channels in nerve membrane at cellular level
 If sodium channel is blocked, impulse is not transmitted
 Different LA drugs differ in side effects, dosages, & duration of action
Electrophysiology of Pain Conduction
 Resting potential = -70mV (unstimulated nerve)
 Action potential - stimulus causes Na channel to open, allowing influx of Na+ ions into axoplasm
 Slow depolarization
o Slow influx of Na+ inos thru channel causes electrical potential to become less negative
o Threshold or Firing Potential = -60 to -50mV; Rapid depolarization begins
 Rapid depolarization
o Rapid influx of Na+ thru channel so that electrical potential quickly reverses to +40mV; Action
Potential is generated
 Repolarization occurs until resting potential is achieved (-60 to -90 mV)
Action of Local Anesthetics: Block the action potential
 Specific Receptor Theory
o Amide-type anesthetics
o LA molecule diffuses thru nerve membrane and attaches to receptor site within Na channel
“blocking” the Na+ ions from passing thru
8. Evolution and Chemical Formulations of Local Anesthetic

Ester-type:
o Metabolized in blood
o Highly allergenic ; metabolite is PABA
o Used only as topical
 Amide-type
o Metabolized in liver & kidneys
o Virtually non-allergenic
o All injectables ; some topical formulations
Specific Protein Receptor Theory
 Binds to receptor site in sodium channel
 Block entrance of sodium ions
 Act during depolarization phase
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9. Local Anesthetic Terminology
PIL – Patient Information Leaflet
Concentration of Drug – what is expressed in a cartridge, 2%, 3% or 4%
Volume – 1.7ml which means (no less than) manufactures variation – FDA requirement
Percentage – expression of the relative amount of drug in a cartridge, 4% drug contains twice as
much drug as a 2% drug
5. Relative contraindications – those in which local anesthetic may be given with caution
6. Absolute contraindications – situations which LA or vasoconstrictor drugs may not be administered
safely
7. Absolute vasoconstrictor contraindications – NO EPINEPHRINE
1.
2.
3.
4.
10. Vasoconstrictors
Definition: A drug added to LA cartridges that constricts the blood vessels
Benefits of Vasoconstrictors
 Constrict blood vessels
 Decrease risk of toxicity
 Prolong duration
 Provide hemostasis via infiltration
Types of Vasoconstrictors
 Epinephrine – 1:50,000, 1:100,000, 1:200,000
 Levonordefrin – synthetic – 1:20,000
 Fight or flight reactions
 Allergy to Epi is impossible
 Mimics allergy symptoms
Maximum Dosage Recommendations
 Healthy patient – 0.2mg per appointment
 Epi-sensitive or Cardiac Dose – 0.04mg per appointment
Sodium Bisulfite
 Preservative added to reduce oxidation of epi
 Contraindications – sulfite allergy
11. Local Anesthetic Choices
What type of anesthesia is needed?
 Topical
 Infiltration
 Field Block
 Nerve Block
Anesthetic Decision Tree
 Topicals
 Compounded Anesthetics
 Non-injectables
 Injectables – Short, intermediate, long acting
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12. Topical Anesthetics
Types of Topical Anesthetics
1. Benzocaine 20%
2. Lidocaine 5%
3. Benzocaine/Tetracaine products
4. Dyclonine Hydrochloride
5. Compounded Products
Indications for Use:
Topical anesthesia is a condition of temporary numbness caused by applying a substance directly to a
surface of the body
Applications
 Gels, sprays, liquids, ointments, pre-measured dose, patch, OTC products
Compounding Pharmacy Drugs
 Anesthetics, mouth rinse, antibiotics, antifungals, cosmetic dental formulations
 Not FDA regulated
 Not tested for safety/efficacy
 FDA Modernization Act 1997 – The compounding product must be individually prescribed for an
identified patient
Common Local Reactions
 Tissue sloughing
 Delayed hypersensitivity
 Redness
 Pain
 Burning at site
Comparing Drugs – Ask questions
13. Non-Injectable Anesthetic
Eutectic Mixture
 Two drugs combined
 Periodontal Gel – Eutectic Mixture of Lidocaine 2.5% + Prilocaine 2.5%
 Quicker uptake
 Longer duration
 Amide Classification
 Pregnancy B drug
 One approved FDA drug
Indication for Use
o Oraqix® is indicated for adults who require localized anesthesia in periodontal pockets during
SRP
Oraqix Application
 Set appropriate expectations for patient
 Apply Oraqix to gingival margin of selected teeth
 Wait 30 seconds
 Insert blunt tip applicator subgingivally, walking thru pocket as Oraqix is dispensed, until the pocket is
full
 Wait 30 seconds, Begin instrumentation
 Re-apply as necessary, up to maximum dosage of 5 cartridges per appointment
Oraqix Dosage
 Oraqix® can be used in combination with injectable anesthetic
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
Can be safely used in any combination, so as not to exceed the MRD of 5 cartridges per appointment
alone or combined with another drug
14. Injectable Anesthetics
Indications for Use
 Control and manage pain during dental procedures
Types
 Lidocaine-Xylocaine-Octocaine
 Articaine-Articadent-Septocaine, Zorcaine
 Mepivacaine-Polocaine-Carbocaine
 Prilocaine-Citanest
 Bupivacaine-Marcaine
Infection
 Changes area to low PH in acidic range
 LA may not be effective
Questions to consider
 Duration of Procedure
 Extent of the treatment needed
 Generalized or Localized
 Need for Hemostasis
Injectable Choices
 Short Acting:
Pulpal duration<1 hour; Soft tissue <2-3 hours
 Mepivacaine 3%
o Produces only slight vasodilatation; adequate duration without the addition of a
vasoconstrictor
 Prilocaine 4% by infiltration
o Epi-free alternative with when longer duration is desired
 Intermediate Acting:
Pulpal duration >60 minutes; Soft tissue >3 hours
 Lidocaine 2% + Epi 1:100,000
o Gold Standard ~ utilized for convenience
 Lidocaine 2% + Epi 1:150,000
o Indicated for hemostasis during periodontal surgery
 Prilocaine 4% + Epi 1:200,000
o Maximum pulpal duration with least amount of vasoconstrictor
 Mepivacaine 2% + Levonordefrin 1:20,000
 Articaine 4% + Epi 1:100,000 or 1:200,000
o Metabolizes faster
 Long Acting:
Pulpal duration > 90-180 minutes; Soft tissue > 4 -9 hours
 Bupivacaine HCL .5% +Epi 1:200,000
Children and Articaine
 Under 4 years of age not investigated
 Remember the solution %
 Simple procedures 0.04%
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15. Dental Innervation

Trigeminal Nerve, V1, V2 and V3
o Opthalmic Branch (V1) –Sensory
o Maxillary Branch (V2) – Sensory
o Mandibular Branch (V3) – Sensory and motor
Injection Types
 Supraperiosteal
o Local infiltration
o Field block, aka “infiltration
 Nerve Block
Maxillary Injections
Nerve
Tissues anesthetized
PSA
Posterior Superior Alveolar
Pulpal/buccal soft tissues of molars, except MB 1st molar (30%)
MSA Middle Superior Alveolar
Pulpal/buccal soft tissues of premolars and MB root 1st molar
ASA
Anterior Superior Alveolar
Pulpal/buccal soft tissues of cuspid and incisors
GP
Greater Palatine
Posterior portion of hard palate to midline
NP
Naso Palatine nerves bilaterally
Anterior one third of hard palate
IO
Infraorbital, ASA and PSA
Pulpal tissue of max central through canine. In 72% of patients
pulpal tissues of max premolars and MB root of 1st molar,
buccal tissue and bone of same teeth, lower eyelid and
lateral portion of nose and max lip
AMSA ASA and MSA
Pulpal tissue of max incisors, canines and premolars. Buccal
Attached gingiva of same teeth, attached palatal tissues from
Midline to free gingival margin on associated teeth
Mandibular Injections
LB
M
Nerve
Inferior alveolar nerve and lingual
nerve
Buccal nerve
Mental
Tissues anesthetized
Mandibular teeth to the midline, buccal mucosa, lip, anterior
Two thirds of tongue, lingual gingiva, floor of the mouth
Soft tissues and periosteum buccal to the mandibular molars
Buccal tissues anterior to mental foramen to midline, skin
of lip and chin
I
Mental and Incisive
Pulpal tissues of premolars, canines & incisors; buccal
Tissues anterior to mental foramen to midline, skin of lower lip
And chin
IA
Failure of Anesthesia
 Anatomical variations
 Infection
 Individual reaction
 Intravascular/intramuscular injection
 Patient Anxiety
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16. Local Anesthetic Complications
 Needle breakage
 Pain on injection
 Burning on injection
 Parathesia
 Trismus
 Hematoma
 Infection
 Edema
 Tissue sloughing
Anesthetic Overdose = CNS toxicity
Symptoms Include:
o Lightheadedness, dizziness, headache
o Visual disturbance
o Sedation
o Numbness or tingling of tongue
o Impaired concentration
o Dysarthria, Tinnitus, Metallic taste
o Muscular twitching
Epinephrine Overdoes
Symptoms include:
o Tension
o Anxiety, apprehension
o Nervousness
o Tremors
o Increased heart rate
o Increased blood pressure
o Throbbing headache
o Hyperventilation
Overdose Management
 Terminate procedure
 Reassure patient
 Position patient comfortably
 Monitor vital signs
 Administer oxygen
 Medical assistance if needed
17. New Horizons
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Local Anesthetic reversal agent
“Gate Control Theory”
Nasal Mist
Buffering Agents
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18. References
1. Ang-Lee, M.K., Moss, J., & Yuan, C. (2001). Herbal Medicines and Perioperative Care. Journal of the
American Medical Association, 286(2), 208-216.
2. Ash-Bernal, R., Wise, R., & Wright, S. (2004). Acquired methemoglobinemia: a retrospective series of 138
cases at 2 teaching hospitals. Medicine, 83(5), 265-73.
3. Basset, K., DiMarco, A.C. (2007). Safety First. Dimensions of Dental Hygiene, 5(10), 20-22, 25.
4. Bassett, DiMarco, Naughton, (2010). Local Anesthesia for Dental Professionals (1st ed.) Boston, MA:
Pearson Education, Inc.
5. Blanton, P.L., Jeske, A.H. (2003). ADA Council on Scientific Affairs; ADA Division of Science,
Avoiding complications in local anesthesia induction: anatomical considerations. Journal of the American
Dental Association. 134(7):888-93.
6. Complications in Local Anesthesia Administration. (2006) Interview with Stanley Malamed.
Dimensions of Dental Hygiene, 4(10): 28-33.
7. Eggleston, S., & Lush, L. (1996). Understanding allergic reactions to local anesthetics. Annuals of
Pharmacotherapy, 30, 851-7.
8. Greer, F., & Shannon, M. (2005). Infant methemoglobinemia: the role of dietary nitrate in food and water.
American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Committee on
Environmental Health. Pediatrics, 116, 784-6.
9. Haas, D., & Lennon, D. (1995). A 21 year retrospective study of reports of paresthesia following local
anesthetic administration. Canadian Dental Journal, 61, 319.
10.Han, Y. W., Fardini, Y. P., Chen, C. D., Iacampo, K. G., Peraino, V. A., Shamonki, J. M., et al. (2010). Term
Stillbirth Caused by Oral Fusobacterium nucleatum. Obstetrics and Gynecology, 115, 442-5.
11. Hersh, E., Hermann, D., Lamp, C., Johnson, P., & MacAfee, K. (1995). Assessing the duration of
mandibular soft tissue anesthesia. Journal of the American Dental Association, 126, 1531-1536.
Injectable Anesthetics. (2003) Journal of the American Dental Association, 134(5), 628-629.
12. Johansen, Orjan, (2004). “Comparison of Articaine and Lidocaine Used as Dental Local Anesthetics”,
Section of Dental Pharmacology and Pharmacotherapy, Institute of Clinical Dentistry, University of Oslo.
13. Kanaa, M., Whitworth, J., Corbet, I., & Meechan, J. (2006). Articaine and lidocaine mandibular buccal
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296-8.
14.Logothetis, D. (2012). Local Anesthesia for the Dental Hygienist (ed., Vol., pp.). St. Louis,
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Missouri: Elsevier, Mosby
15. Malamed, S. (1993). Managing medical emergencies. Journal of the American Dental Association, 124(8),
40-53.
15. Malamed, Stanley F., (2004) Handbook of Local Anesthesia, Fifth Ed., St. Louis, Missouri: 10 DENTSPLY
Professional 10/25/2013 Elsevier, Mosby
17. Markman, L. (2009). Teething: facts and fiction. Pediatric Review, 30, 59-64.
18. Moore, P., Boynes, S., & Hersch, E. (2006). The anesthetic efficacy of 4% articaine 1:200,000 epinephrine.
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19. Pogrel, M. (2009). Broken local anesthetic needles: a case series of 16 patients, with recommendations.
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20. Rose, L. F., Mealey, B., Minsk, L., & Cohen, D. W. (2002). Oral care for patients with cardiovascular
disease and stroke. Journal of the American Dental Association, 133(Supplement) 37S-44S.
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mandibular posterior teeth. Journal of the American Dental Association,138(8), 1104-1112.
22. Rubin, Rick J., DMD, MPA, Saad, Ali Y. DMD (2010), Dental Hygiene Local Anesthesia, Dental Board
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23. Rutherford, B., Zeller, J. R., & Thake, D. (2009). Local and Systemic Toxicity of Intraoral Submucosal
Injections of Phentolamine Mesylate (OraVerse). Anesth Prog, Winter;56(56), 123-127.
24. Scofield, J. (2007). The Gravity of Methamphetamine Addiction. Dimensions of Dental Hygiene, 5(3), 1618.
25. Smith, T., & Heaton, L. (2003). Fear of dental care: Are we making any progress? Journal of the American
Dental Association, 134(8), 1101-1108.
26. Spolarich, A., & Andrews, L. (2007 Summer). An examination of the bleeding complications associated
with herbal supplements, antiplatelet and anticoagulant medications. Journal of Dental Hygiene, 81(3), 67.
Epublish July 2007.
27. Whitcomb M, Drum M, Reader A, Nusstein J, Beck M, A Prospective, Randomized, Double-Blind Study of
the Anesthetic Efficacy of Sodium Bicarbonate Buffered 2% Lidocaine With 1 : 100,000 Epinephrine in
Inferior Alveolar Nerve Blocks,
28. Anesthesia Progress, Vol. 57, No. 2, P. 59 (2010).
29. http://www.acog.org/publications/guidelinesForPerinatalCare/gpc-83.pdf
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30. http://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/pages/Teething-4-to-7Months.aspx2
Web Sites
29. American Association of Nurse Anesthetists: www.aana.com
30. American Botanical Council: www.herbalgram.com
31. FDA Center for Food Safety and Applied Nutrition: www.cfsan.fda.gov
32. Herbal Interactions, Mayo Clinic: www.mayoclinic.com
33. [email protected]
34. NIH-National Center for Complementary and Alternative Medicine: http://nccam.NIH.gov
35. American Heart Association: www.americanheart.com
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