Anesthesia & Sedation

Updated for 2018

Though local anesthetics are safe and effective, considerable research is on-going to make them even more effective. Computer-controlled local anesthetic delivery systems (C-CLAD) and buffered local anesthetic solutions promise to allow painless injections to be delivered to dental patients almost anywhere in the oral cavity. Fear of injections is primarily based on the needle. The development of an intranasal local anesthetic mist has been shown to provide successful pulpal anesthesia of maxillary teeth – without a needle. Epinephrine is added to injectable local anesthetics to increase their effectiveness, duration and safety. However the duration of residual soft tissue anesthesia – usually unnecessary and occasionally a potential danger – is extended when epinephrine is used in the anesthetic solution. Self-inflicted soft tissue injury is a real problem associated with this anesthesia in all patient age groups but especially pediatric and geriatric patients. Phentolamine mesylate – an alpha adrenergic antagonist – has been shown to significantly reduce the duration of residual soft tissue anesthesia when administered at the conclusion of the traumatic part of dental treatment.

Learning Objectives: 

1. Discuss the current research on intranasal local anesthesia in dentistry
2. Describe the effect of pH on the onset, depth & comfort of anesthesia with local anesthetics
3. Describe the mechanism of action of the buffering agent sodium bicarbonate on local anesthetics
4. List the benefits of local anesthetic buffering in dentistry
5. Discuss the local anesthetic reversal agent - phentolamine mesylate
6. Describe the advantages & disadvantages of Computer-Controlled Local Anesthetic Delivery (C-CLAD)
7. Describe the clinical effects of the intranasal local anesthetic mist

Updated for 2018

Articaine HCl was introduced in the USA in 2000 and has become a very popular anesthetic agent. Though classified as an amide local anesthetic it is actually a hybrid molecule, possessing both ester and amide characteristics. With epinephrine, articaine provides approximately 60 minutes of pulpal anesthesia and between 3 to 5 hours of soft tissue anesthesia. Its unique molecular characteristics make articaine a preferred anesthetic in the pregnant and the nursing patient as well as the lighter weight (<30kg) pediatric patient. However, articaine is used as a 4% solution and there has been some concern about the possibility of 4% anesthetics possessing a greater risk of producing paresthesia than local anesthetics used in lesser concentrations.

This program provides an in-depth look at articaine, its advantages and disadvantages when compared with other commonly used dental local anesthetics. We also discuss the ‘controversy’ alleging an increased risk of paresthesia following administration of 4% local anesthetics.

Learning Objectives:

1. Describe the clinical characteristics that make articaine HCl ‘different’
2. Compare articaine HCl clinically to other dental local anesthetics
3. Discuss the use of articaine HCl in pediatrics; (2) pregnancy and (3) nursing
4. Discuss the use of articaine HCl in (1) pregnancy and (2) nursing
5. Discuss the ‘controversy’ over prolonged anesthesia (paresthesia) as related to injectable local anesthetics in dentistry

Updated for 2018

Complications associated with local anesthetic administration are rare. This program discusses complications occurring in and around the site of local anesthetic drug administration - facial nerve paralysis, hematoma, paresthesia, trismus and needle breakage, their prevention, recognition and management as well as the two systemic adverse drug reactions – allergy and overdose – are reviewed as each relates to the administration of local anesthetic drugs.

Learning Objectives:

1. Name 5 localized complications associated with administration of dental local anesthetics
2. Discuss the mechanism of and signs & symptoms associated with multiple complications
3. Name the three systemic adverse drug reactions (ADRs)
4. Discuss the differences between allergy & overdose
5. List the components of a local anesthetic cartridge and potential allergic reactions
6. Describe the signs & symptoms of local anesthetic overdose

Updated for 2018

Local anesthetic techniques providing pain control in the maxillary arch are described in this program following a review of the anatomy of the trigeminal nerve. Techniques include infiltration (supraperiosteal), anterior superior alveolar nerve block; middle superior alveolar nerve block; posterior superior alveolar nerve block; anterior superior alveolar nerve block; and palatal injection techniques.

Learning Objectives:

1. Select the appropriate maxillary injection technique for the planned dental procedure
2. Name the branches of the Vth cranial nerve and discuss their relevance to dental treatment
3. Describe the indications for, and technique of, maxillary infiltration
4. Describe the indications for, and technique of, the posterior superior alveolar nerve block
5. Describe the indications for, and technique of, the anterior superior alveolar nerve block
6. Describe the indications for, and technique of, the anterior middle superior alveolar nerve block
7. List the recommended volume of local anesthetic solution for each maxillary injection technique

Updated for 2018

Techniques of anesthesia in the mandible are reviewed in this program, including the traditional inferior alveolar, Gow-Gates, Vazirani-Akinosi, and incisive nerve blocks as well as several non-traditional injection techniques including the periodontal ligament injection, intraosseous anesthesia and the administration of the local anesthetic articaine HCl by mandibular infiltration in adult patients.

Learning Objectives:

1. Select the appropriate mandibular injection technique for the planned dental procedure
2. Describe the indications for, and technique of, inferior alveolar nerve block
3. Describe the indications for, and technique of, incisive nerve block
4. Describe the indications for, and technique of, the Gow-Gates mandibular nerve block
5. Describe the indications for, and technique of, Akinosi-Vazirani Mandibular nerve block
6. List the recommended volume of local anesthetic solution for each mandibular injection technique
7. List the indications and contraindications for the periodontal ligament injection
8. List the indications for, and technique of, intraosseous anesthesia
9. Discuss the success of articaine HCl when used by infiltration in the adult mandible

Updated for 2018

The basic armamentarium for the administration of local anesthetics includes the syringe, cartridge and needle. Proper assembly and use of these items minimizes the risk of complications arising during injection, such as shattering of cartridges and needle breakage. Prior to the administration of drugs the doctor is expected to have knowledge of the health status of the patient receiving the injection. The medical history questionnaire is reviewed with an emphasis on local anesthetic-related concerns. As the delivery of ‘painless’ injections is foremost on the patient’s list of dental desires, the basic local anesthetic injection technique is reviewed.

The basic armamentarium for local anesthetic delivery – the syringe, cartridge and needle – is reviewed in this program along with evaluation of the patient prior to receiving an injection. A step-by-step review of the basic local anesthetic injection technique is provided.

Learning Objectives:

1. List & describe the function of the items of local anesthetic armamentarium
2. Describe the reason behind, and the technique of, aspiration
3. Describe the proper assembly of the local anesthetic armamentarium
4. List & give examples of ASA 1 through ASA 4 patients
5. List & describe the basic local anesthetic injection technique

Updated for 2018

Local anesthetics, the most used drugs in dentistry, are the safest & most effective drugs for the prevention and management of pain. However the act of receiving an injection – the ‘shot’ – is the most fear-inducing part of the dental experience for most patients. 75% of all dental office medical emergencies are ‘stress’ related and therefore preventable in most situations. Techniques of managing fear including inhalation and oral sedation are reviewed. The pain reaction threshold (PRT) is introduced followed by a discussion of the effect of various clinical situations, e.g. pain, infection and fear, on the PRT. The currently available (in North America) local anesthetic formulations are discussed with an emphasis on their expected duration of clinical action.

This program reviews the development of local anesthetics and the drug formulations that are currently available in dentistry. The effect of fear & anxiety on local anesthetic effectiveness is discussed along with an introduction to sedation – a very important ally in the quest for effective pain control.

Learning Objectives:

1. Describe the effect of dental fear & anxiety on the pain reaction threshold
2. Describe the normal distribution curve and how the clinical actions of local anesthetics are reflected by it
3. List those medical emergencies precipitated in the dental environment by fear, anxiety and inadequate pain control
4. List the ester-type local anesthetics and compare their clinical actions to the currently used amide-type local anesthetics
5. Discuss the chemical & clinical differences of articaine HCl from other currently available local anesthetic formulations