A Review of Local

Anesthesia Techniques
Adapted from Dr. Stanley F. Malameds
Handbook of Local Anesthesia

Rebecca J. Love DDS

Larilyn Dang RDH, B.S.
Vaughn Hixson RDH, B.S.
Sandra Wilkie RDH, M.S.
Alana Woffinden RDH

Roseman University, College of Dental Medicine



Block Syllabus
Block Title Local Anesthesia Lab
Curriculum Thread Oral Maxillo-Facial Surgery
Block Number 6300
Block Director Dr Erin Greene D.D.S., Assistant Professor; egreene@roseman.edu
Block Instructor Dr Pete Emmons D.D.S., Assistant Professor; pemmons@roseman.edu
Block Description Demonstration and administration of nine local and regional nerve blocks are
experienced in a supervised lab setting that includes proper needle safety
measures. Minimal competence is verified through successful completion of
proficiency evaluations.
CODA Standards 2-9, 2-11,2-12,2-14, 2-17, 2-19, 2-20, 2-23e, 2-23m
CODM Competencies 1c, 2c, 6c, 9c, 10c, 17c
Assessed CODM
Competencies
Learning Resources Malamed, Stanley F., Handbook of Local Anesthesia, 6th Ed, St. Louis MO: Mosby
2014
Rebecca J. Love, D.D.S., Local Anesthesia Handbook
Kris Munk, DMD and Rebecca J Love DDS Local Anesthesia Technique Videos,
Roseman University of Health Sciences CODM
Skull
Methods of Assessment Hands on injection skills, under observation, successfully completing each injection
three times for pass-off with a Final Practical showing proficiency in the Inferior
Alveolar Nerve Block and the Posterior Superior Nerve Block.
Assessment Description Students will be evaluated by means of written assessments and group projects.
As in all Roseman University CODM blocks, a 90% assessment score is necessary for
Pass, and less than 90% will constitute No Pass. A No Pass will necessitate
participation in Remediation/Reassessment at the scheduled time.
Students will also be evaluated on their ability to support the Lifelong Colleague
Philosophy of the College, which states that at the Roseman University College of
Dental Medicine, students, faculty and staff are expected to make each and every
interaction reflect a sincere desire to develop one another as lifelong colleagues
during the program, and throughout their professional careers.
Block Conduct and Grading Criteria:
Protocols
Learning to become a professional involves much more that accumulating facts.
The learning theory informs us that there are three domains or areas to learning
and if we incorporate all three areas, our comprehension is enhanced (MacDonald,
Nowakowski, Schonwetter, 2012). In an effort to make your learning most effective
this block has several components and students must pass all components to pass
the block. Those components are evaluated as:
Didactic Assessments (cognitive domain)
Students must achieve 90% on assessments to demonstrate mastery of
the content. Students not passing assessments at 90% must remediate
before progressing.

DMD number and Name 1
 Pre-clinic/Clinical Skills/Break-out sessions (psychomotor domain)
Students will be evaluated on their skills, products and performance.
Students not passing must remediate before progressing.

Professionalism (affective domain)

Students must also demonstrate mastery of several areas related to
professionalism.
Some areas that will be evaluated are:
w Attendance
w Participation
w Appropriateness of attire
w Respect
Each day you will be evaluated. If you are found in violation your
instructor will notify you and review expectations. Any student
demonstrating repetitive or extreme behavior will fail the block and need
to remediate before progressing. Repeated extreme behavior may be
grounds for dismissal from the program.

Please see student handbook for guidelines related to summer remediation for
those student not passing a block.

Course Objectives 1. Under direct supervision, demonstrate safe administration of the following
injections to clinical competency, at least three times
a. Posterior Superior Alveolar injection (PSA)
b. Middle Superior Alveolar injection (MSA)
c. Anterior Superior Alveolar injection (ASA)
d. Greater Palatine injection (GP)
e. Nasopalatine injection (NP)
f. Inferior Alveolar Nerve Block injection (IAN) including Lingual (L)
g. Long Buccal Nerve Block injection (LB)
h. Mental/Incisive Nerve Block injection (M/I)
2. Student will be able to evaluate whether local anesthesia is appropriate
using medical histories and physical exam and choose the appropriate
topical and injectable anesthetic, evaluating drug interactions, health
status, and physical status learned in didactic courses to determine what is
best for the patient
3. Student will perform all injections with appropriate asepsis technique
being prepared to handle situations arising in a professional manner.
Examples are: dropping the needle cap, contaminating the needle,
harpoon is not engaged for aspiration, harpoon sticking to plunger,
positive aspiration, premature osseous contact, etc.
4. Student will be able to perform all injections using effective techniques, be
able to describe landmarks, point of penetration, optimum depth and
angle of needle, proper dose of anesthetic for a particular nerve block,
possible contraindications and complications with a given injection along
with procedures to handle a local or vasoconstrictor emergency, and
alternatives, if any, to different injections.
5. Formulate local anesthesia prescription for patient based on health history,
patients personal anatomy, age, sex, weight, procedure, and length of
time of proposed procedure

DMD number and Name 2
 Block Schedule
Day 1
AM
Introductions, Course Objectives
Expectations, Lab Manual
M alamed Video Local Anesthesia Disc 1
The Agents Amides/ Esters Summary Sheet
Case Studies MRD Calculations & LA Rx
Topical Anesthetic
Dem o - Armamentarium Tray Set Up
Needles- Gauges and Lengths
Dem o Needle Gauges (Neutrogena Soap)
Deflection, Aspirating, Lengths: Long vs Short Maxilla
Syringe Assem bly - carpule
(engaging harpoon) and needle
Dem o/Practice - Positive Aspiration (Disclosing
Solution)
Dem o/Practice Rate of Deposition
Dem o/Practice Single Handed Recapping
PM
Dem o/Practice- Needle Penetration & Osseous
Contact (Banana, Peach)
Practice -Single Handed Re-capping
Anatom y Review- M SA
Practice MSA on Skulls
M alamed Video M SA
Operator/Patient Positioning
Practice- Single Handed Recapping
Syringe Disassembly
Safe Disposal of Needle & Cartridge
DMD number and Name 3
Day2
AM
Video/Demo Oraquix
Physical and Psychological Evaluation
Vitals, ASA Classification, Absolute and Relative
Contraindications/Allergies
Overdose/M RD & Vasoconstrictors
Summary Sheets
Case Studies Medically compromised Record
Keeping
Penetration Depth & Dosage Summary Sheet
Anatomy Review - ASA
Syringe Assembly
Practice ASA on Skulls
M alamed Video ASA
Success and Com plications of LA
Operator/Patient Positioning
Practice Single Handed Recapping
CLINIC - ASA (Bilateral)
Vital Signs
Dry tissue
Place topical anesthetic- 1 min
Verbiage:
o I will be using 3% M epivacaine Plain -
Proceed
o Site of Penetration - Proceed
o Optimum Depth & Angle - Proceed
o Aspirating - + or - ? Proceed
o Slowly deposit one stopper full -
Withdraw
o Single Handed Recapping
o Syringe, Disassembly Safe Disposal
PM
Adverse Events
Prevention and Management Needle Breakage,
Hematoma
Anatomy Review M ental/Incisive
Practice Mental/Incisive on Skulls
M alamed Video Mental/ Incisive
Operator/Patient Positioning
Practice Single Handed Recapping
 CLINIC M SA (Bilateral)
Vital Signs
Dry tissue
Place topical anesthetic- 1 min
Verbiage:
o I will be using 3% M epivacaine Plain -
Proceed
o Site of Penetration - Proceed
o Optimum Depth & Angle - Proceed
o Aspirating - + or - ? Proceed
o Slowly deposit one stopper full -
Withdraw
o Single Handed Recapping
o Syringe, Disassembly, Safe Disposal
CLINIC M ental/Incisive (Bilateral)
Vital Signs
Dry tissue
Place topical anesthetic- 1 min
Verbiage:
o I will be using 3% M epivacaine Plain -
Proceed
o Site of Penetration - Proceed
o Optimum Depth & Angle - Proceed
o Aspirating - + or - ? Proceed
o Slowly deposit one stopper full -
Withdraw
o Single Handed Recapping
o Syringe, Disassembly, Safe Disposal

University Policies & Assistance

Ethics and This block requires students to uphold the Roseman CODM Honor Code contained in the
Professionalism Student Handbook. It also adheres to the policy on professionalism fully described in
the Student Handbook. These responsibilities include:
Attend all scheduled instructional periods (p. 11). Attendance implies arriving
promptly at the start of the session and remaining until its conclusion.
Foster a positive environment for learning (p. 38), including being engaged in team
and class projects.
Abide by basic standards of honesty and academic integrity and respect for others
outlined in the Life Long Colleague Principle (p.3) and as stated in the Honor Code: I
will not lie, cheat, steal, disrespect others nor tolerate among us anyone who does (p.
38).
Use appropriate attire as specified in the Student Handbook (p. 13-14) and Clinic
Manual (p. 7).
Promote the good of every patient in a caring, compassionate, professional and
confidential manner (p. 38).
Abide by the White Coat Pledge to never approach a clinical situation unsupervised
knowing that treating patients is offered to me under the auspices of my supervisors
license (p. 3).
Follow proper infection control protocols and maintain respect for CODM facilities and
equipment as outlined in the Clinic Manual.
Professional progress is being monitored. If there are concerns with your professional
progress, you will be notified. Students demonstrating repetitive or extreme behavior
may fail the block and would need to remediate before progressing. Infractions of
professional progress can result in academic sanctions as defined in the policies and
procedures pertaining to student professionalism section of the student handbook.
Academic Academic integrity is a legitimate concern for every member of the campus community;
Misconduct all share in upholding the fundamental values of honesty, trust, respect, fairness,
responsibility and professionalism. Students enrolling in Roseman CODM assume the
obligation to conduct themselves in a manner compatible with Roseman College of
Dental Medicine function as an educational institution. An example of academic
DMD number and Name 4
 misconduct is plagiarism: Using the words or ideas of another, from the internet or any
source, without proper citation of the sources.
Copyright and Fair The University requires all members of the University Community to familiarize
Use Requirement themselves with and to follow copyright and fair use requirements. YOUR ARE
INDIVIDUALLY AND SOLELY RESPONSIBLE FOR VIOLATIONS OF COPYRIGHTS AND FAIR
USE LAWS. THE UNIVERSITY WILL NEITHER PROTECT NOR DEFEND YOU OR ASSUME ANY
RESPONSIBILITY FOR EMPLOYEE OR STUDENT VIOLATIONS OF FAIR USE LAWS.
Violations of copyright laws could subject you to federal and state penalties and criminal
liability as well as disciplinary action under University policies.
The information provided to you in this block in the form of handouts, outlines,
synopses, PowerPoint presentations, tests, etc. are the intellectual property of the
individual faculty. These materials are provided for student use only within the domain
of the Roseman College of Dental Medicine. Use of this material by students outside the
University setting or distribution of this material to anyone not affiliated with Roseman
CODM constitutes a copyright violation.
Falsification of The Roseman College of Dental Medicine prohibits the forgery and falsification of any
Documents documents or records. This includes, but is not limited to, the forging, altering, misusing,
providing or causing any false information to be entered on ANY University or College of
Dental Medicine PRINTED OR ELECTRONIC documents, records (including patient
records), or identification cards. The falsification of data, improper assignment of
authorship of school work or other scholarly activity, claiming another persons work as
ones own, unprofessional manipulation of experiments or of research procedures, or
misappropriation of research funds will not be tolerated. Commission of any act of
forgery or falsification as described will result in disciplinary action and sanctions.
Observance of As a general rule, a student missing a class or laboratory assignment because of
Religious Holidays observance of a religious holiday shall have the opportunity to make up missed work.
Students must notify the block director of anticipated absences at the beginning of block
instruction to be assured of this opportunity. Faculty may give students an additional
week to complete missed work, but must set clear deadlines. Note: Students who
represent Roseman CODM at any official extracurricular activity shall also have the
opportunity to make up assignments, but the student must provide official written
notification to the instructor no less than one week prior to the missed class(es).

DMD number and Name 5

 Local Anesthesia Supply List

Classroom
1-Foam Tray
1-2X2 Gauze
1-Cotton Rolls
1-Long Tip Cotton Tip Applicators
1-Aspirating Syringes (School Inventory)
2-Anesthetic Needles (1-27 Short and 1-27 Long)
3-Anesthetic Carpules (Carbocaine/Mepivacaine)
20 cups
1-Sharps Container in Classroom
Gloves (S, M, L, XL)

Clinic
1-Foam Tray
4-2X2 Gauze
2-Cotton Rolls
Long Tip Cotton Tip Applicators
Air-Water Syringe
Saliva Ejector
Topical Anesthetic
Anesthetic Needles (27 Short or Long)
Anesthetic Carpules (Carbocaine/Mepivacaine)
 Fulcrums

A B C

Examples of appropriate fulcrums during the administration of local anesthetics using

the mirror for retraction.

A. Elbow tucked into side of body for stabilization. B, C, D. Pinky of dominant hand
resting on patients chin.
 Armamentarium

Loading the syringe
Engage the harpoon. While holding the syringe as if injecting, gently push the piston
forward until the harpoon is firmly engaged in the plunger. Excessive force is not
necessary. DO NOT HIT THER Piston, because this frequently leads to shattered or cracked
glass cartridges (Malamed, 2013).

The expiration date of the anesthetic MUST be visible in the large window. Have the
syringe, large window side down, on the tray. Pick the syringe up and it will immediately
turn over in your hand so that the large window is face up.

Recapping: The One-Hand Technique
Many accidental needle sticks occur during the recapping of needles. To safely recap use
the one-hand technique:

Step 1

Place the cap on a flat surface, and then remove your hand from the cap.

Step 2

With one hand, hold the syringe and use the needle to scoop up the cap.

Step 3

When the cap covers the needle completely, use pressure against a firm surface to secure
cap on the needle. NO NOT hold the card or cap.
 Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS

ASA: Needle: 27 S

Chair Position (RH) 10 oclock; (LH) 2 oclock

Insertion Site: Height of mucobuccal fold, medial to the canine eminence

Advance Needle: Parallel to long axis of the canine following the contour of the maxilla. Angle
needle from insertion point to point of deposition above the apical area of canine at the height
of canine fossa.

Needle Depth: 3-6 mm

Deposit Amount: - carpule

Area Anesthetized

Point of Insertion

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

 Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS

MSA: Needle: 27 S

Correct Position: (RH) Face patient from 10 oclock (LH) Face patient from 8 or 9 oclock

Insertion Site: Height mucobuccal fold, above second premolar

Advance Needle: Parallel long axis of tooth until tip well above apex of second premolar

Needle Depth: 5-8mm

Amount Deposit: - carpule

AREA ANESTHETIZED (Remember 50-78% people do NOT have an MSA)

POINT OF INSERTION & DEPTH

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed
Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS PSA

PSA: Needle: 27 S

Clinician Position: (RH) Left PSA: 10 oclock Right PSA: 8 oclock

(LH) Left PSA: 2 oclock Right PSA: 4 oclock

Insertion Site: Height of mucobuccal fold, distal to DF cusp of second molar

Advance Needle: Mouth partially open, mandible oriented to side of injection. Advance needle
slowly in upward, inward, and backward direction. (Think of bisecting a cube, using head as
cube)

Upward: Superiorly at 45 to occlusal plane

Inward: Medially toward midline at 45 to occlusal plane (parallel ala of nose)

Backward: Posteriorly at 45 angle to long axis of 2nd molar

Slowly advance needle to proper depth (16 mm or 4/5 of a short needle, leaving 4mm showing)

Deposit Amount: to 1 full carpule

SITE OF PENETRATION AND ANGLES

We will be using a SHORT needle so as to reduce chances of causing a hematoma by injecting too far
posteriorly into the pterygoid plexus. In smaller adults and children, advance the needle to a depth of
10-14 mm only. Remember, a short needle is 20 mm long.

The PSA may need to be supplemented by a local infiltration over the MB root of the 1st molar in 28% of
patients. (These patients will have an MSA)

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS PSA

DEPTH OF PENETRATION FOR A LONG (A) /SHORT (B) NEEDLE (We will do B)

AREA ANESTHETIZED

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

 Roseman University COCM LOCAL ANESTHESIA: MAXILLARY INJECTIONS

GP: Needle: 27 S

Clinician Position: For visual and seating comfort, plus pressure anesthesia

Insertion Site: Locate Greater Palatine Foramen by placing a cotton swab at the junction of the
alveolar process and the hard palate, starting at the 1st molar and palpate with swab posteriorly
until the swab drops into the GPF depression. (Most frequent location distal to 2nd molar)
Apply topical for 2 minutes, then apply PRESSURE anesthesia DIRECTLY OVER the foramen for a
minimum of 30 seconds. The tissue will blanch if pressure performed with enough force. Insert
just ANTERIOR to the cotton swab. DO NOT penetrate through the swab! This is needle
contamination and the needle will need to be changed immediately. Syringe barrel will come
from opposite corner of mouth with needle coming to injection site at a right angle.

Advance Needle: At right angle to tissue, and anterior to cotton swab, place bevel against tissue
but NOT penetrating tissue. Slightly bowing needle, push a droplet of anesthetic onto tissue,
straighten the needle and penetrate tissue. Keep injecting in front of the needle as progress
through tissue slowly. Contact palatine bone and deposit anesthetic.

Needle Depth: 4-6 mm

Amount Deposited: - 1/3 carpule SLOWLY over 30 seconds

AREA ANESTHETIZED

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

 Roseman University COCM LOCAL ANESTHESIA: MAXILLARY INJECTIONS

PALPATING FOR FORAMEN

INSERT ANTERIOR TO COTTON SWAB

MAINTAIN PRESSURE ANESTHESIA THROUGHOUT INJECTION

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS NP

NP: Needle: 27 S

Clinician Position: (RH) 9 or 10 oclock facing same direction as patient (LH) 3 or 2 oclock.

Patient open wide, neck extended

Insertion Site: Apply topical for 2 minutes, then pressure anesthesia directly over incisive
papilla. At equator of papilla, lateral to cotton swab, place bevel against tissue and slightly bow
needle. Without penetrating tissue, force anesthetic droplet against mucosa. Still applying
pressure anesthesia, straighten needle and penetrate tissue

Advance Needle: While continuing pressure anesthesia with cotton swab, slowly advance
needle toward incisive foramen while pushing small amount of anesthetic ahead of the needle
until bone is gently contacted. Withdraw 1mm.

Needle Depth: Normally 5 mm or less

Amount Deposited: cartridge

AREA ANESTHETIZED

ANGLE AND DEPTH OF NEEDLE

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MAXILLARY INJECTIONS NP

ALTERNATIVE THREE PENETRATION TECHNIQUE

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MANDIBULAR INJECTIONS IANB

IANB: Needle: 25 L (27 L acceptable) 30 gauge is NEVER appropriate except in pediatric dentistry but
one needs to inject even slower! Difficult to aspirate with a 30 gauge needle. The IA has a 10-
15% positive aspiration rate.

Correct Position: (RH) Right IANB 8 oclock Left IANB 10 oclock

(LH) Right IANB 4 oclock Left IANB 2 oclock

Insertion Site: Landmarks: 1. Coronoid Notch (greatest concavity on anterior border of ramus)

2. Pterygomandibular raphe (vertical position)

3. Occlusal plane of mandibular teeth

Parameters: 1. Height of injection

2. Anterio-posterior needle placement

3. Depth of penetration

Height of Injection: Line from coronoid notch to deepest part of pterygomandibular

raphe

Palpate coronoid notch and visualize an imaginary line from this point posteriorly
to the deepest part of the pterygomandibular raphe (point where the raphe
transitions vertically toward the maxilla). This line should parallel the occlusal
plane of the mandiblular teeth (approximately 6-10 mm above the occlusal plane).

Anteroposterior Site of Injection: At intersection of (1) horizontal line from coronoid

notch to deepest part of pterygomandibular raphe as it ascends vertically toward the
palate, and (2) vertical line through horizontal line about three-quarters back from
anterior border of ramus (coronoid notch).

Depth of Penetration: 20-25mm or 2/3 to length of a long needle. Bone should be

contacted and withdraw 1mm. (See Troubleshooting Sheet if no bone contacted)

Advance Needle: Once site of penetration has been located and visualized, stretch tissues taut
laterally from the coronoid notch. Place the barrel in the commissure of the lip on the
contralateral side. Barrel should be over the contralateral mandibular premolars. Penetrate
tissue and procede to depth and bony contact. (See Troubleshooting Sheet if have premature
osseous contact OR no bone contact is made)

Needle Depth: 20-25 mm to contact bone (2/3 -3/4 length of long needle)

Amount Deposit: 1.5 1.7 ml (Leave one and one-half stopper full as needed for long buccal
block)

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MANDIBULAR INJECTIONS IANB

AREA ANESTHETIZED

NOTE: Must perform a long buccal nerve block to anesthetize buccal tissue of molars

PTERYGOMANDIBULAR RAPHE RECOGNITION

INJECTION SITE AND DEPTH; THUMB ON CORONOID NOTCH

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

 Roseman University CODM LOCAL ANESTHESIA: MANDIBULAR INJECTIONS LB

LONG BUCCAL NB

Needle: 25 or 27 L Use same needle as for IA

Chair Position: (RH) Right: 8 oclock; face patient Left: 10 oclock; face same direction

(LH) Right 2 oclock; face same direction Left: 4 oclock; face patient

Insertion Site: Mucous membrane distal and buccal to most distal molar in the arch

Advance Needle: Slowly until gentle contact with bone

Needle Depth: Usually 1-2mm. May be as deep as 4mm

Deposit Amount: 0.3mL (One and one half stoppers full)

AREA ANESTHETIZED

INJECTION SITE AND DEPTH

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

Roseman University CODM LOCAL ANESTHESIA: MANDIBULAR INJECTIONS M/I

MENTAL/INCISIVE NB: Needle: 25 or 27 gauge short

Correct Position: Below patients line of site. 12 oclock OR 8-9 oclock

Insertion Site: Mucobuccal fold, just anterior to mental foramen (check pantograph but usually
insert between to premolars or between canine and first premolar)

Advance Needle: Slowly toward mental foramen

Needle Depth: 5-6mm

Amount Deposit: Mental NB: 0.6ml (1/3 carpule) Incisive NB: 0.9ml (1/2 carpule)

For incisive nerve block, Rub with pressure for one to two minutes to force the LA into
the mental foramen

AREA ANESTHETIZED

INJECTION SITE AND DEPTH

Photos, drawings, and information are taken from Handbook of Local Anesthesia, 6th Edition, 2013
Stanley F. Malamed

 Roseman University CODM TROUBLE-SHOOTING INJECTIONS/INJECTION COMPLICATIONS

DISENGAGED HARPOON: One MUST be able to aspirate on all injections, other than the PDL.
Therefore, one MUST withdraw the needle, re-engage the harpoon, and insert needle again.

IANB:

PREMATURE or NO BONE CONTACT:

Almost immediately hit bone: (Too far anterior) Withdraw, reevaluate correct location,
and reinsert needle. OR, withdraw, reinsert, with needle angled more posteriorly.

Less than one-half length of long needle:

Withdraw needle slightly.

Swing syringe barrel medially over the canine or lateral incisor on the contralateral side
of injection.

Redirect needle until tip is around the bony obstruction, swing back over the premolars
in the corner of the mouth, and take until proper depth and angle, after contacting bone.

Do NOT hit bone: (usually too far posterior meaning MEDIAL). To correct, withdraw
needle until only about or 8 mm of needle are left in the tissue. Reposition the barrel more
POSTERIORLY (over mandibular molars). Re-insert until bone contacted (depth of 20-25mm). DO NOT
DEPOSIT LOCAL ANESTHESIA IF BONE IS NOT CONTACTED. NEEDLE MAY BE IN THE PAROTID GLAND
NEXT TO THE FACIAL NERVE. This may lead to TRANSIENT FACIAL PARALYSIS.

ANESTHETIC FAILURE: MOST COMMON CAUSES

1. Deposition inferior to mandibular canal opening. CORRECTION: Re-inject higher

2. Deposition too far anteriorly (laterally) on the ramus. Needle usually hit bone prematurely.
CORRECTION: Redirect needle tip posteriorly
3. Accessory Innervation: Primary symptom is isolated areas of incomplete pulpal anesthesia
in the molar region, most commonly MESIAL OF FIRST MOLAR. Maybe cervical innervation,
but most common is MYLOHYOID NERVE innervation. CORRECTION: Mylohyoid nerve block,
or Gow-Gates mandibular nerve block PDL injection, Intraosseous Injection (see Advanced
Local Anesthesia Injections),
4. Bifid inferior alveolar nerve (detected on panograph): Second mandibular foramen located
more inferiorly. CORRECTION: Deposit second carpule of anesthetic inferior to the normal
anatomic landmark.
5. Incomplete anesthesia of the central and lateral incisors. Usually nerve fiber cross-over
from contralateral side (rarely from mylohyoid nerve). CORRECTION: Buccal and lingual
infiltration, contralateral incisive nerve block, PDL injection.

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM TROUBLE-SHOOTING INJECTIONS/INJECTION COMPLICATIONS

HEMATOMA/ TRISMUS WITH IANB: (Second most common injection for hematoma)

1. HEMATOMA is rare but will usually manifest itself as a swelling on the medial side of the
ramus after delivery of anesthetic. TREATMENT: Pressure on the medial aspect of the ramus
and ice pack to the area for 3-5 minutes. (See hematoma management below)
2. TRISMUS: muscle soreness or limited movement
a. MILD: Some soreness and slight limited movement following an IANB is normal
i. Heat therapy: Hot, moist towels q20/60 minutes
ii. Warm saline rinses: 1t salt / 8 oz warm water; held in mouth on involved
side and expectorated
iii. Analgesics: 325 mg aspirin q6h
iv. Muscle relaxants (if needed): 10 mg diazepam bid
v. Physiotherapy: Open/close/ lateral excursions of mandible 5 minutes q3-4
hours. (Chewing sugarless gum helps lateral movement of jaw)
b. SEVERE PAIN/DYSFUNCTION/ NO IMPROVEMENT IN 2-3 DAYS (ON ANTIBIOTICS) OR
5-7 DAYS NOT ON ANTIBIOTICS
i. Refer to OMS:

PSA:

HIT BONE DURING INJECTION

The PSA injection should never hit bone. Withdraw needle, reassess landmarks, and
reinsert in proper location. Be sure to note if individual is missing their first bicuspids
(from orthodontia) and feel that distance more posterior to the second molar. You
should then be in soft tissue.

HEMATOMA CAUSE & TREATMENT: PSA MOST COMMON INJECTION TO CAUSE HEMATOMA

1. Commonly caused from inserting needle too far posteriorly into the pterygoid venous
plexus. The maxillary artery may be nicked. Main vessels harmed are the posterior superior
artery (primarily), the facial artery, and the pterygoid plexus of veins. Use of a SHORT
needle minimizes the risk of pterygoid plexus infringement. *DO NOT DO A PSA ON A
PERSON TAKING BLOOD THINNERS
2. A visible hematoma will develop in minutes. It may first appear as a colorless swelling on
the face near the TMJ area.
3. TREATMENT: No ideal physical place to apply pressure to stop hemorrhaging. The bleeding
will continue until the pressure from the extravascular blood is equal to or greater than the
intravascular blood. Pressure may be applied to the soft tissues of the mucobuccal fold as
distally as the patient can tolerate. Apply pressure in a medial and superior direction. Apply
ice extraorally to help increase pressure to the site and to help constrict the punctured
blood vessel(s). The patient will develop an ugly facial bruise.
4. MANAGEMENT:
a. Discharge patient ONCE HEMORRHAGING IS STOPPED.

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM TROUBLE-SHOOTING INJECTIONS/INJECTION COMPLICATIONS

b. Note hematoma in patient record
c. Advise patient about possible soreness and limitation of movement (trismus).
i. If trismus develops, start trismus protocol listed above under IANB
d. Advise patient of probable bruising that will gradually resorb over 7-14 days.
e. Take NSAIDs for soreness.
f. Apply ice to region immediately following notice of hematoma
i. Analgesic
ii. Vasoconstrictor
iii. Minimize size of hematoma
g. Do not apply heat to area for 4-6 hours
i. Heat produces vasodilation of blood vessels.
h. Heat MAY be applied to the area at the beginning of the next day.
i. Analgesic properties
ii. Causes VASODILATION and MAY increase rate of reabsorption of blood
products back into the blood stream.
iii. Warm moist heat q20min/hour
i. TIME!!!! Will last 7-14 days
j. Avoid additional dental treatment until signs and symptoms resolve.

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Local Anesthesia Injections: Location, Depth, Dosage

Chair Anesthetic Needle
Injection Area Anesthetized Site of Penetration Depth
Position Dose

Tooth & soft tissue @ Comfortable Mucobuccal fold @ 27 S
Infiltration 3-6 mm 1/3 carp
site Position apex of target tooth

Central, lateral,
Mucobuccal fold 1/2 3/4 27 S
ASA canine teeth & facial 10 oclock 3-6 mm
medial to canine fossa carp
gingiva
Premolars, Left
sometimes MB root 8-9 oclock Mucobuccal fold @ 1/2 - 3/4 27 S or
MSA st nd 5-8 mm
1 molar, & facial Right 2 premolar carp L
gingiva 10 oclock
Left
Mucobuccal fold distal
Molars except for MB 10 oclock 27 S
PSA st to 2nd molar 16 mm to 1 carp
root 1 molar Right
pterygopalatine fossa
8 oclock

No teeth, but palatal Lateral to widest area 27 S
NP 8-10 oclock 4-7 mm 1/4 carp
gingiva of ant. of incisive papilla

Depression just
Left anterior to GP
No teeth, but nd 4-6 mm
11 oclock foramen ( 2 Molar) 1/4 1/3
GP posterior palatal less than
Right midway between carp 27 S
gingiva 10 mm
7-8 oclock median raphe and
gingival margin
Lateral to
All teeth in quad with
Left pterygomandibular
buccal gingiva from
IA 10 oclock raphe, height of 1.5 mL
premolars to midline, 21-24 mm
w/Lingual Right coronoid notch, & 5/6 carp 25 L
floor of mouth, ant.
8 oclock medial to internal
2/3 of tongue
oblique ridge
Left
Buccal gingiva of 10 oclock Buccal fold distal to Less than 0.3 mL 25 or
LB
mandibular molars Right last mandibular molar 3-4 mm 1/6 carp 27 L
8 oclock
Tissue @ site with
Below Buccal gingiva near
buccal gingiva 1/3 carp 25 or
Mental patients line mental foramen 5-6 mm
midline- premolars 27 S
of site (usually by premolars)

1/3 - 1/2
Incisive: Pulp, teeth Below Buccal gingiva near carp

Incisive & gingiva from patients line mental foramen 5-6 mm Rubbing
27 S
midline - premolars of site (usually by premolars) pressure for
1 min

Adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed


 Advanced Local Anesthesia Injections: Location, Depth, Dosage

Injection Area Anesthetized Site of Penetration Depth Anesthetic Dose Needle

Gow-Gates Nerves Anesthetized: IA, Lingual, M/I, Mucous membrane on mesial of mandibular 1.8-3.0mL
V3 Nerve Block Mylohyoid, Auriculotemporal, LB (75% of ramus, distal to 2nd molar, on line from 1 to 1-2/3 carpule 25 or 27 L
(Open Mouth) patients) intertragic notch to corner of mouth (Height at 25mm (variable) Mouth wide open 1-2 min, sit upright after
Areas associated with above nerves ML cusp 2nd) injection. Bite block helps.
5 min until anesthesia
Vazirani-Akinosi Nerves Anesthetized: IA, lingual, M/I, Soft tissue overlying medial border mandibular 1.5-1.8mL
(Closed Mouth) mylohyoid ramus adjacent to maxillary tuberosity at height 25 mm 1 carpule 25L
of mucogingival junction max 3rd molar Sit patient upright after injection

Mylohyoid Pulpal tissue anterior to injection site Lingual mandible, apical region tooth posterior 3-5 mm 0.6mL 25 or 27 L
to tooth in question 1/3 carpule
Maxillary Nerve Block Pulpal Maxillary same side, buccal Height mucobuccal fold above distal aspect of 1.8mL
V2 Nerve Block periodontium & bone, soft tissue and max 2nd molar 1 carpule 25 -27 L
High Tuberosity bone hard palate, part of soft palate (advance inward, upward, outward as for PSA) 30mm (3-5 min until anesthesia)
Approach medial to midline, skin lower lid, side
nose, cheek, upper lip
V2 Nerve Block Same as above Palatal soft tissue directly over greater palatine 30mm 1.8mL 25 - 27 L
Greater Palatine foramen. Give GP block, needle at 45 to bone 5-15% have 1 carpule
Approach to enter GP canal. Advance slowly blockage (3-5 min to anesthesia)
Do not force
AMSA Central, lateral, canine & premolar teeth Junction of vertical and horizontal aspect of C-CLAD
(Good for anterior with entire unilateral palate gingiva & palate between premolars 4-7 mm 3/4 to 1 carp WAND
cosmetic dentistry) facial gingiva from premolars to central. Inject over 3-4 minutes 27 S
Unilateral Anes NO LIP or MFE (Use Wand or C-Clad)
P-ASA Pulps Max centrals & laterals, less so on Lateral to incisive papilla in papillary groove. 6-10 mm 1.4-1.8mL C-CLAD
(Anterior Cosmetic canines. Facial & palatal soft tissues of SLOW entry as injecting ahead and enter canal Inject over 3-4 minutes WAND
Dentistry) same. NO LIP or MFE (Use Wand of C-Clad) 27 S
Bilateral Anes
Infraorbital Nerve Pulps Max central to canine, 72% of Height of mucobuccal fold directly over the 1st 16mm 0.9 to 1.2 mL (over 30 to 40 seconds)
Block (IO) pulps of Max premolars & MB root of 1st premolar (Generally) to carpule
molar. Buccal periodontium and bone of Advance until 25 -27 L
same teeth. Lower eyelid, lateral aspect bone is contacted
of the nose & upper lip. at upper rim of
infraorbital
foramen
PDL Bone, soft tissue, apical and pulpal Long axis of tooth on the mesial and distal of MAY need to 0.2ml (ONE stopper) over 20 sec per spot
tissues in area of injection the root (one rooted) and interproximally on bend needle
the root of multi-rooted teeth. Advance down & 27S
against root until
resistance met
Intraosseous Terminal nerve endings of area, & Must be able to perforate cortical plate Requires See Malamed Ch 15, Supplemental Injections
adjacent hard and soft tissues Stabident, X-Tip,
Intraflow

Adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed


 Roseman University CODM Absolute & Relative Contraindications for LOCAL ANESTHETICS


ABSOLUTE: Documented allergy to local anesthetic drug. If one is allergic to one ester, one is
allergic to ALL esters. Usually, if one is allergic to one amide, one will not be allergic to another. Do not
use local anesthetic in either case until patient has been seen and tested for LA allergy by an allergist.

RELATIVE CONTRAINDICATION:

ASSOCIATED DISEASE SIGNIFICANCE

Malignant hyperthermia Use amides judiciously. NOT generally associated
with dental amide anesthetics. Usually associated
with general anesthetic doses of halothane and
succinylcholine
Atypical pseudocholinesterase NO ESTERS. Use amides only
Significant liver dysfunction (ASA IV) Judicious use of amides/esters. All may be used,
but consider articaine as only 5-10% is
metabolized in the liver; the other 90-95% is
metabolized in the blood.
Renal dysfunction Judicious use of amides and esters.
Methemoglobinemia (congenital or acquired, AMIDE use: NO prilocaine nor benzocaine topical
oxygenation diseases, meds such as APAP,
nitrates (antianginals), sulfonamides)
Significant cardiovascular disease. Patients Limit vasoconstrictor to Cardiac Dose. i.e. 0.4mg
taking digoxin (Lanoxin), enalapril (Vasotec), epinephrine or 0.2mg levonordefrin.
furosemide (Lasix) Use cardiac dosing with vasoconstrictor (no more
than 2 carpules
2% lidocaine 1:100K epi,
2% mepivicaine 1:20k levonordefrin,
4% articaine 1:100K epi) ,
Low or no vasoconstrictor LAs
4% articaine 1:200K epi,
0.5% bupivacaine 1:200K epi,
4% prilocaine 1:200K epi,
4% prilocaine plain,
3% mepivicaine)
Clinical hyperthyroidism Use cardiac dosing above
Patients taking cimetidine (Tagamet, Zantac) on DO NOT USE LIDOCAINE
regular basis
Drug reduces capacity of liver to metabolize
Cimetidine and ASA 3 + heart failure amides, REDUCE DOSAGE ALL AMIDES by ONE-
HALF
ANTI-ANXIETY DRUGS: benzodiazepines REDUCE ALL LAs by ONE-HALF

Adapted from: Pain Control for Dental Practitioners; Paarmann & Royer; 2008

 Roseman University CODM Absolute & Relative Contraindications for VASOCONSTRICTORS

ABSOLUTE:

Recent myocardial infarction (within past 3-6 months)

Recent coronary bypass surgery (within past 3-6 months)
Uncontrolled high blood pressure
Daily angina or uncontrolled arrhythmias
Sulfite allergies (especially patients with steroid-dependent asthma)
Uncontrolled diabetes (causes hyperglycemic effect)
Pheochromocytoma: catecholamine-producing tumors
Uncontrolled hyperthyroidism

RELATIVE: LIMIT EPI to 0.04mg (unless otherwise noted. See controlled diabetes); 1 carp 1:50K epi;
2 carp 1:100K epi; 4 carps 1:200K epi. LIMIT LEVONORDEFRIN to 0.2mg (2 carps)

ASSOCIATED DISEASE SIGNIFICANCE

Tricyclic Antidepressants: eg. triptyline, AVOID LEVONORDEFRIN! Epinephrine effects
-ipramine Examples: Elavil, Norpramin, Tofranil, increased. Both may cause acute hypertension &
Aventyl, Vivactil, etc cardiac dysrhythmia.
Phenothiazides: eg. phenazine, -promazine, - Increased risk of hypotension; epinephrine
dazine. Examples: Tindal, Thorazine, Trilafon, stimulates beta receptors; combined with drug
Vesprin, Mellaril, etc creates unbalance in body
Nonselective Beta Blockers: eg. Propranolol Increased hypertension resulting in rebound
Examples: Inderol, Corgard, Blocadren bradycardia; potential cardiac arrest; if hemostasis
&/or time is not essential, consider using LA
without vasoconstrictor
Glaucoma Limit vasopressor; causes increased ocular
pressure
Controlled Diabetes Vasoconstrictors directly oppose effect of insulin.
Possible changes in blood levels of glucose. LIMIT
EPINEPHRINE TO THREE CARPULES OF 1:100K EPI.
FOUR CARPULES 1:100K EPI elicits glycogenoLYSIS
in liver and skeletal muscle, elevating blood sugar
levels in the blood plasma.
Controlled Hyperthyroidism Vasoconstrictor effect increased
Controlled High Blood Pressure Very controversial; risks associated with
vasoconstrictors-increase in blood pressure
Cocaine Abusers Cocaine stimulates norepinephrine release and
inhibits its reuptake. May cause tachycardia &
dysrhythmias, which in turn, increase cardiac
output & O2 needs. Ischemia lead to MI, CVA.
NEVER USE EPI IMPREGNATED GING RETR CORD!

Adapted from: Pain Control for Dental Practitioners; Paarmann & Royer; 2008
 Roseman University CODM OVERDOSE: LOCAL ANESTHETIC

COMPARISON OF ALLERGY AND OVERDOSE

ALLERGY OVERDOSE
NON-Dose Related Dose Related
Signs & Symptoms: Similar, regardless of allergen Signs & Symptoms: Relate to pharmacology of
drug administered
Management: Epinephrine, histamine blockers Management: Specific for drug administered
*Idiosyncrasy: Qualitatively abnormal, unexpected responseusually a GENETIC response
* Estimated that 99% of all true ADRs (Adverse Drug Reactions) are overdose related

LOCAL ANESTHETIC OVERDOSE: PREDISPOSING FACTORS

PATIENT FACTORS DRUG FACTORS

AGE Vasoactivity
WEIGHT Concentration
Other Drugs DOSE
Sex Route of Administration
Genetics RATE of INJECTION
Presence of Disease Vascularity of Injection Site
Mental Attitude & Environment Presence of VASOCONSTRICTORS
OVERDOSE LEVELS: SIGNS AND SYMPTOMS

LEVEL SIGNS SYMPTOMS

Low to Moderate ELEVATED BP Metallic Taste
ELEVATED HR Visual Disturbances- Focus
ELEVATED Respiratory Rate Tinnitus
Talkativeness Drowsiness/Disorientation
Apprehension Loss of Consciousness
Excitability Lightheadedness/Dizziness
Slurred Speech Restlessness
StutterMuscle Twitch Twitching Sensation Before
Tremor Distal Extremties Visible Twitching
Euphoria Numbness
Dysarthria Nervousness
Nystagmus
Sweating
Vomiting
Disorientation
Loss of pain response
Failure to follow Commands
Moderate to High Overdose Tonic-Clonic Seizures CNS
Depression DEPRESSED BP,
HR, Respiratory Rate
***Administration of too large a dose relative to body weight (and age) of the patient is the most
common cause of serious local anesthetic overdose reactions in dentistry. Remember MRDs!***

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM OVERDOSE: LOCAL ANESTHETIC

MANAGEMENT OF LA OVERDOSE

BASIC EMERGENCY MANAGEMENT

CONSCIOUS UNCONSCIOUS
P POSITION Patient Comfort SUPINE; Feet elevated slightly
A AIRWAY Assess Airway Assess and maintain airway
B BREATHING Assess Breathing Assess and ventilate as necessary
C CIRCULATION Assess Circulation Assess and provide compressions
if necessary
D DEFINITIVE CARE DIAGNOSIS: Slow, Slower,
Rapid Onset (See below)
MANAGEMENT: Emergency MANAGEMENT: Emergency drugs
drugs and/or 9-1-1 AND 9-1-1

MILD OVERDOSE: Patient CONSCIOUS, talkative, agitation, HR, BP, Respirations-develop slowly

SLOW ONSET ( 5 MINUTES AFTER ADMINISTRATION)

Possible Causes: Rapid Absorption; Too Large of Total Dose

Definitive Care: Follow PABCD

1. Reassure patient
2. Administer O2 via nasal canula or nasal hood (REASONING: Prevents acidosis
that decreases seizure threshold of LA leading to tonic-clonic seizures)
3. Monitor and record vital signs
4. Permit patient to recover as long as necessary before dismissal. Consider
calling 9-1-1 if not confident of patient response.

SLOWER ONSET (> 15 MINUTES AFTER ADMINISTRATION)

Possible Causes: Abnormal biotransformation and renal dysfunction

Definitive Care: Follow PABCD

1. Reassure patient
2. Administer O2
3. Monitor and Record Vital Signs
4. Administer an anticonvulsant. (REASONING: Overdose caused by abnormal
biotransformation OR renal dysfunction PROGRESS in intensity and last
longer due to inability to eliminate drug). IV midazolam preferable.
a. Titrate 1 mg of midazolam(Versed)/minute until clinical signs and
symptoms of overdose subside.

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM OVERDOSE: LOCAL ANESTHETIC

5. SUMMON EMERGENCY MEDICAL CARE/ CALL 9-1-1
a. Anticonvulsant administration will intensify postexcitement
depression
b. Monitor patient status
c. Basic life support
6. If patient is not transported to hospital by EMS, make sure patient has an
escort before leaving the dental office
7. After termination of reaction, make sure patient seeks medical consultation
to determine possible causes.
8. Do not proceed with additional dental therapy requiring local anesthetics
until cause of reaction is determined.

SEVERE OVERDOSE REACTION

RAPID ONSET (within 1 minute) Loss of consciousness with or without convulsions

Possible Cause: Intravascular injection

Definitive Care: Follow PABCD

PABC Place patient in SUPINE position, feet slightly elevated. Monitor

and record vital signs. A, B, and C assessed and maintained.

WITH CONVULSIONS:

1. Protect patients head and extremities; loosen clothing, REMOVE

HEADREST PILLOW
2. 9-1-1 IMMEDIATELY
3. Continue BLS: Adequate airway and ventilation CRITICAL for LA induced
tonic-clonic seizures
a. Seizure Physiology
i. Increased oxygen utilization and hypermetabolism
ii. Increased production of CO2 and lactic acid
iii. Both leading to acidosis
1. Acidosis lowers seizure threshold and prolongs
reaction
iv. Cerebral blood flow increased during seizure, elevating LA
blood levels within the CNS
4. ADMINISTER AN ANTICONVULSANT IF SEIZURE LASTS MORE THAN 4-5
MINUTES WITH NO LETTING UP and properly trained (IV, IM, or IN). NOT
indicated for seizure terminated within 1-3 minutes. FOLLOW UP WITH BLS
AND EMS
a. IV (Intra-Vascular) midazolam (PREFERRED)
i. 1mg/minute until seizure terminates

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM OVERDOSE: LOCAL ANESTHETIC

b. IM (Intra-Muscular) midazolam
i. 0.2mg/kg adult or child
ii. Site of Injection: vastus lateralis preferred
c. IN (Intra-Nasal) Patients weigh less than 50kg
i. 0.2mg/kg (up to 10 mg)
ii. Seizures usually stop after 1-2 minutes
5. Postseizure (Postical) Phase
a. Signs and Symptoms: CNS depression usually at intensity of
excitation phase.
i. Drowsy or unconscious
ii. Breathing shallow or absent
iii. Airway partially or totally obstructed
iv. MORE INTENSE POSTSEIZURE STATE IF PATIENT GIVEN AN
ANTICONVULSANT.
6. PABC
a. Position: Supine
b. Airway: Assess and maintain
c. Breathing: May need assisted or positive pressure ventilation
d. Circulation: Chest compressions may be necessary in severe cases
7. Additional Management
a. Hypotension Initial Treatment
i. Positioning patient supine
ii. IV fluids
b. Hypotension Persists (Past 30 min)
i. Ephedrine (vasopressor) IM:
c. Allow patient to rest until able to go to hospital ER for evaluation

SLOW ONSET OF SEVERE REACTION (5 - 15 minutes)

Possible Causes:

1. Too large dose of LA

2. Rapid absorption
3. Abnormal biotransformation
4. Renal Dysfunction

Definitive Care Follow PABCD

1. Administer and anticonvulsant and oxygen

2. EMS/ 9-1-1 if seizure develops
3. Post-Seizure: BLS and IM or IV administration of vasopressor PRN
4. Allow patient to recover as long as necessary before discharge to hospital
5. Completely evaluate patients condition before readministering LA

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

 Roseman University CODM OVERDOSE: VASOCONSTRICTORS

SIGNS SYMPTOMS
SHARP elevation in BP, primarily systolic Fear, anxiety
Elevated heart rate Tenseness
Possible cardiac dysrhythmias (premature Restlessness
ventricular contractions, ventricular tachycardia,
ventricular fibrillation)
THROBBING headache
Tremor
Perspiration
Weakness
Dizziness
Pallor
Respiratory difficulty
Palpations

TREATMENT

MOST COMMON CAUSE OF EPINEPHRINE OVERDOSE IS EPINEPHRINE IMPREGNATED

GINGIVAL RETRACTION CORD. REMOVE IMMEDIATELY! CONTRAINDICATED IN PEOPLE WITH
CARDIOVASCULAR DISEASE
Most instances of vasoconstrictor overdose are short in duration, so no formal management is
necessary. IF duration is longer, some management is appropriate.
o Terminate the procedure, and if possible, remove the source of vasoconstrictor.
o PABCD
POSITION: Semi-supine or upright (further minimizes elevation of cerebral BP
ABC (Patient talking and conscious)
DEFINITIVE CARE:
REASSURE the patient: Signs and symptoms are transient and will
subside shortly
MONITOR VITAL SIGNS: Administer Oxygen (unless hyperventilating)
o BP & HR checked q5minutes during episode
Recovery: Let patient sit in chair as long as necessary to recover. If self-
care is in doubt, wait for responsible person to release patient to.

Information adapted from Handbook of Local Anesthesia, 6th Edition, 2013 Stanley F. Malamed

Per U.S. Car 1.8ml: (B) 0.5%=9mg; (L&M) 2%=36mg; (M Plain) 3%=54mg; (P&A) 4%=72mg
Epi: 1:50K=0.036mg; 1:100K=0.018mg; 1:200K=0.009mg; Levonordefrin: 1:20K=0.09mg
MRD OF VASOCONSTRICTORS
(Heart dose = 20% of a healthy patient dose)
Vasoconstrictor Healthy Max # Carps *Heart Disease *Carpules Disease
epi 1:100k 0.2 mg 11 0.04 mg 2.2 or 2
epi 1:50k 0.2 mg 6 0.04 mg 1.1 or 1
epi 1:200k 0.2 mg 22 0.04 mg 4.4 or 4
levonordefrin aka 1 mg 11 0.2 mg 2.2 or 2
Neocobefrin 1:20k
*MRD IS BASED ON 150 lb PATIENT. IF THEY WEIGH MORE, IT IS STILL BASED ON A
150 lb PATIENT. Patient weighs < 150 lb; MRD by lb or kg up to absolute maximum MRD
*MEDICALLY COMPROMISED PATIENT = DIVIDE IN HALF
*CARDIAC DOSE applies to the VASOCONSTRICTOR, NOT the LA =1/5 MRD vasoconstrictor
*WHEN LOOKING FOR MG PER ML, USE %x10: 0.5%=5mg/ml, 2%=20, 3%=30, 4%=40mg/ml
mg/lb to mg/kg (Change lbs to kgs)= DIVIDE by 2.2
mg/kg to mg/lb (Change kgs to lbs)= MULTIPLY by 2.2

Recommended Volumes of Local Anesthesia for Maxillary Techniques

Technique Volume, mL Carpule Amount Pediatric, mL
Infiltration 0.6 1/3 0.3
Posterior Superior Alveolar (PSA) 0.9-1.8 - 1 0.45
Middle Superior Alveolar (MSA) 0.9-1.2 -
Anterior Superior Alveolar (ASA) 0.9-1.2 - 0.45
Anterior Middle Superior Alveolar (AMSA) 1.4-1.8
Greater Palatine (GP) 0.45-0.6 -1/3 0.2
Nasopalatine (NP) 0.45 (max) 1/4 0.2
Supraperiosteal (Infiltration) (I) 0.6 1/3
Recommended Volumes of Local Anesthesia for Mandibular Techniques
Technique Volume, mL Carpule Amount Pediatric, mL
Inferior Alveolar (IA) 1.5 5/6 0.9
Long Buccal (LB) 0.3 1/6
Mental (M) 0.6 1/3 0.45
Incisive (IN) 0.6-0.9 1/3- 0.45
Gow-Gates 1.8-3.0
Vazirani-Akinosi 1.5-1.8

(g)eneric vs. (T)rade Name______________________________________________

bupivacaine (Marcaine, Vivacaine)
lidocaine (Xylocaine, Octocaine, Lignospan)
mepivacaine (Carbocaine, Polocaine, Scandonest, Isocaine)
prilocaine (Citanest (plain), Citanest Forte (fortified with epinephrine))
articaine (Septocaine, Zorcaine)

PEDIATRIC DOSES

CLARKS RULE YOUNGS RULE

Childs Weight in Lbs x MRD MRD x Childs Age

150 lbs (12+ Childs Age)

Stanley Malamed D.D.S.: Handbook of Local Anesthesia, Sixth Edition and Kathy Bassett RDH: Local Anesthesia for Dental Professionals;
Pulpal & Soft Tissue Anesthesia Page Rebecca J Love DDS, PC
 Amide Local Anesthetic Information
LA Band MRD MRD MRD Onset of Pulpal Soft Tissue Duration Pregnancy Contraindications Indications
Anesthesia
Color (mg/ (mg/ Absolute (Minutes) Anesthesia Anesthesia Category Category For Use For Use
Code lb) kg) # Carps Metabolism (Minutes) (Minutes) Half-Life Cautions with Use
0.5% None None 90 mg 6-10 minutes 90-180 240-540 Long C Not Recommended: Long dental appointment:
bupivacaine Listed Listed May need to MALAMED:>90 MALAMED: 1.Child Pulpal anesthesia >90
1:200,000 10 carps start with 240-720 2.7-3.5 hours 2.People with Mental &/or minutes
epinephrine another LA Physical Disabilities Post operative pain
*MOST 3. Geriatrics management
TOXIC LA Liver Compromised CVS
3% 3.0 6.6 400 1.5 2 minutes 20-40 120-180 Short C Children, geriatric
mepivacaine 7.5 carps Weak VasoD Dr M: 5-10 (I) Dr M: 90-120 114 minutes patients, bisulfite allergy
2% 3.0 6.6 400 1.5 2 minutes 60 180-300 Intermediate C CV ASA 3-4 (Blocks/levo)
mepivacaine Hyperthyroidism (B/levo)
1:20,000 levo 11 carps LIVER 114 minutes Tricyclic Antidepressants-
Malamed p 149 (levo C/I)
2% lidocaine 3.2 7 500 2-3 minutes 60 180-300 Intermediate B Nonselective blockers Hemostasis: Surgery
1:50K ASA 3-4: CV &
epinephrine 6 carps-epi LIVER 96 minutes Hyperthyroidism
2% lidocaine 3.2 7 500 2-3 minutes 60 180-300 Intermediate *B Allergy: bisulfites *Lidocaine 1:100k LA of
1:100K epi 11 carps-epi LIVER 96 minutes LA of Choice Nonselective blockers Choice for Pregnancy
4% prilocaine 4.0 8.8 600 2-4 minutes 10-15 Infiltrate 90-120 (I) Short B *SAFEST of Amides Bisulfite Allergy Prilo Pl
Plain 40-60 Block MALAMED; 60- (Infiltration) Methemoglobinemia *Prilo Plain LA of Choice :
8 carps Weak VasoD 120 (I) Intermediate APAP Sulfonamides Epinephrine sensitive
120-240 (B) (Block) Nitrates patients requiring pulpal
Hypoxic Cardiac/ anesthesia > 60 minutes
*Metabolized 96 minutes Respiratory Failure WHY? Rapid
in liver, LUNG, Hemoglobinopathies biotransformation, i.e.
KIDNEY Anemias Low toxicity
Paresthesia: Especially
lingual nerve
4% prilocaine 4.0 8.8 600 2-4 minutes 60-90 180-480 Intermediate B Methemoglobinemia *Prilocaine LA of Choice:
1:200,000 APAP Sulfonamides Epinephrine sensitive
epinephrine 8 carps 96 minutes Nitrates Hypoxic Cardiac/ patients requiring pulpal
*Metabolized Respiratory Failure anesthesia > 60 minutes
in liver, LUNG, Hemoglobinopathies CV DZ, brittle diabetics
KIDNEY Anemia Paresthesia: Especially
lingual nerve
4% articaine 3.2 7 None-Based (I) 1-2 minutes 75 180-360 Intermediate C Allergy: ESTERS, bisulfite Nursing Mother-Why?
1:100,000 on pt weight (B) 2-3 minutes MALAMED: MALAMED: Caution: Liver Disease Liver Disease
epinephrine 11 based on *Metabolized 60-75 180-300 43.8 minutes CV disease, Breast Paresthesia: Especially
epinephrine liver & BLOOD Feeding, Children < 4years lingual nerve
4% articaine 3.2 7 None-Based (I) 1-2 minutes 45 120-300 Intermediate C Allergy: ESTERS, bisulfite Nursing Mother-Why?
1:200,000 on pt weight (B) 2-3 minutes MALAMED: MALAMED: Caution: Liver Disease, CV Liver Disease
epinephrine 22 based on *Metabolized 45-60 180-240 44.4 minutes Disease, Breast Feeding, Paresthesia: Especially
epinephrine liver & BLOOD Children < 4 years lingual nerve

DURATION OF LA ACTION: Shortest to Longest; mepivacaine> lidocaine> prilocaine> articaine> bupivacaine Rebecca Love DDS, PC
ABSOLUTE C/I: TRUE Amide & Bisulfate Allergy; RELATIVE C/I: ASA 3-4 for liver, renal, CV & hyperthyroidism dysfunction Page 1

 ADA Color Coding for Local Anesthesia & Needles

Local Anesthetic Drug ADA Color Coded Band

-Lidocaine 2% 1:50,000 epinephrine Green
Lidocaine 2% 1: 100,000 epinephrine Red
Mepivacaine 3% Plain Tan
Mepivacaine 2% 1:20,000 levonordefrin Brown
Prilocaine 4% Yellow
Prilocaine 4% 1: 200,000 epinephrine Black
Articaine 4% 1:100,000 epinephrine Silver
Articaine 4% 1:200,000 epinephrine Gold
Bupivacaine 0.5% 1:200,000 epinephrine Blue

Needle Size & Gauge ADA Color Coding ADA Color Coding
30 Gauge X-Short Pale Lavender
30 Gauge Short Blue See Through with Blue Band
27 Gauge Short Coral See Through with Yellow Band
27 Gauge Long Yellow
25 Gauge Short Red See Through with Red Band
25 Gauge Long Red

Advantages of Larger Gauge Needles over Smaller Gauge Needles

Less deflection from intended path as needle is penetrated through significant tissue
Greater accuracy in achieving target location
Increased chance of success of the injection
Less chance of needle breakage
Aspiration is easier to achieve and more reliable
NO DIFFERENCE in patient comfort!
 Adverse Events of Local Anesthesia

Hematoma from failure

to aspirate

Hematoma from failure to

aspirate

Self-inflicted soft tissue
lip injury

 Adverse Events of Local Anesthesia

In this image a case of Occulomotor palsy which is seen as a

complication of inferior alveolar nerve block when it is given into the
parotid gland and affects the Facial nerve

Diagram to show how an inferior

alveolar nerve block can afflict the
facial nerve if the local anesthetic is
given too far posterior and the
needle does not contact bone:
(a) normal, (b) injection into
parotid gland where facial nerve
can be affected
 Needle Breakage

Figure 1: Panorex using 2 localizing needles shows broken Figure 2: Computed tomography scan (axial cut) with part of a
needle visualized in the right pterygomandibular space (yellow arrow).

Practitioners can reduce the incidence of needle breakage by being vigilant and aware of all the
factors that increase the chance of needle breakage. Injections should never be attempted without the
patient's full participation and cooperation, as sudden movements have been reported to be the cause
of needle breakage.1,11 Needles should not be used for multiple injections. They become more blunt
with use, making each subsequent injection more painful to the patient and requiring more pressure
to pierce the tissue; increased pressure on the needle increases the likelihood of breakage.1,2

Some practitioners have argued that smaller needles are more susceptible to breakage. Several
authors recommend using at least a 27-gauge needle for all blocks2,7,12 as most breakage occurs with
a 30-gauge or smaller needles.1,6 It should also be noted that most patients cannot detect a significant
difference between a 27-gauge and a 30-gauge needle.13,14 Pressure on injection is often more painful
with a 30-gauge needle and negates any advantage gained in piercing the tissue with a smaller
needle.14,15

The weakest point of a needle is the needlehub junction.10,16 Therefore, a needle must be of
adequate length to ensure that it is never buried to the hub.2 Most dental schools caution against
bending needles to achieve access, but many clinicians teach and use this technique. A bend
introduces another weakness in the needle in addition to the susceptible hub; thus, a needle should
never be inserted into the tissue past a bend or up to the hub. Adhering to this rule ensures that,
should a needle break, it can be easily retrieved, as part will be extruding from the tissue.

A broken needle is a rare but serious complication in dental treatment, and every effort must be made
to prevent it. Should a needle break, the practitioner must note how it occurred, take appropriate
radiographs, document the case well and refer the patient to an oral surgeon immediately for
treatment.

Rifkind, J.B. (2011). Management of a Broken Needle in the Pterygomandibular Space Following a
Vazirani-Akinosi Block: Case Report. J Can Dent Assoc 2011;77:b64.

 Oraqix

Easy-to-Use Blunt Tip Applicator Puts Oraqix Exactly Where

Needed Oraqix can be ready for your patients in mere seconds. Typically, one cartridge (1.7g) or
less of Oraqix is sufficient for one quadrant of the dentition. The specially designed blunt-tip applicator
allows dentists and dental hygienists to target the areas to be worked on during scaling and root planing
procedures.
Apply Oraqix to the base of the periodontal pocket in two steps; first to the gingival margin around
the selected teeth, then after 30 seconds, to the periodontal pockets.
Wait 30 seconds and begin procedure

Tips and Tricks for Best Results To maximize the effects of Oraqix, ensure
it is applied at the base of the periodontal pocket in the following manner:

Apply Oraqix on the gingival margin around the selected teeth

Wait 30 seconds
Fill periodontal pockets until the gel becomes visible at the gingival margin
Wait 30 seconds and begin treatment

When administered, Oraqix should be a liquid. In its liquid state, an air-bubble should be visible and
freely floating. If it has turned to gel, it should be refrigerated until it becomes a liquid. Do not freeze
Oraqix. If you have trouble expressing Oraqix from the dispenser, it is possible the Oraqix may have
warmed up too much during handling and turned to a gel. Try cooling the Oraqix cartridge and try again.

Purge the Air Bubble. To ensure optimal dispensing performance, the air-bubble should be purged
from the cartridge prior to use. To purge the air bubble, after loading Oraqix into the dispenser, hold the
dispenser vertically and press the paddle 1-2 times. To create a better guidance tip, the cap of the
dispenser can be used to create a double bend in the applicator.
 ROSEMAN UNIVERSITY CODM PROGRAM
LOCAL ANESTHESIA LEARNING EXPERIENCE/PROCESS EVALUATION
Student: Date:

Patient: ______________

Circle One: IA/LB, ASA, MSA, PSA, NP, GP, Incisive/Mental

Circle One: Right / Left

TASK: COMMENTS:
1. Medical History & Vitals: Identifies any concerns or contraindications
2. Assembles armamentarium including syringe, needle, anesthetic cartridge, topical anesthetic,
2x2 cotton gauze, cotton tip applicator, saliva ejector, a/w syringe tip, mirror & cotton pliers
3. Properly assembles syringe with correct anesthetic type for patient (always check expiration
date)*
4. Expels a few drops to determine free flow of solution
5. Makes sure large window of syringe is facing down on tray so that as operator approaches
patient with palm up grasp, cartridge is clearly visible*
6. Warms loaded syringe in palm of hand for 30 seconds if needed, to bring to room
temperature
TECHNIQUE:
7. Places patient in appropriate position for specific injection
8. Dries retraction area & anesthesia site (removes any debris)
9. Applies small amount of appropriate topical anesthetic to area for a minimum of one minute.
10. Communicates the procedure to the patient using proper terms to avoid increasing patient
fears.
11. Establishes a firm fulcrum with hand or elbow.
12. Re-dries tissue and pulls tissue taut (using gauze for stabilization)
13. Keeps syringe out of patients line of sight
14. Does not touch needle to ANY surface but injection site*
15. Making sure bevel is toward the bone, penetrates tissue at appropriate site and states: I am at
minimum penetration and waits for permission to proceed.
16. Watches for patient reaction as proceeds, reassuring patient as needed
17. Proceeds to the optimum deposition site and states: I am at maximum depth and angle and
waits for permission to proceed.
18. States: Aspirating while doing so. Reports positive or negative aspiration and waits for
permission to proceed.*
19. If needed, appropriately deals with positive aspiration.
20. Slowly injects anesthetic solution (at least 60 seconds per 1.8 ml cartridge)
21. Uses appropriate amount of anesthetic for specific injection
22. Continues to appropriately monitor & communicate with patient
23. Slowly withdraws syringe & safely recaps the needle (scoop technique)*
24. Observes patient for at least 5 minutes afterwards for any adverse reaction
POST-PROCEDURE:
25. Safely removes cartridge & needle from syringe.
26. Disposes of needle & cartridge in sharps container*
27. Maintains aseptic technique throughout

Comments: ___________

_________________________

________________________________________________________________________________________________________

Instructor Signature/ #: _________________________________

Individual Anesthesia Techniques

Maxillary Anesthesia Comments on Individual

Anesthesia Techniques:
Posterior Superior Alveolar
27 gauge short needle (long acceptable)
Area of Insertion: Height of the mucobuccal fold above the maxillary second molar Circle One: PSA, MSA, ASA
Advance needle: Upward superiorly at a 45 angle to the occlusal plane GP, NP, AMSA, IAN, IN, LB
Inward medially toward the midline at a 45 angle to the occlusal plane
Backward posteriorly at a 45 angle to the long axis of the second molar
Depth of penetration: short = of the length; long = of the length.

Middle Superior Alveolar

27 gauge short needle
Area of Insertion: Height of mucobuccal fold above the maxillary second premolar
Advance needle: Parallel with long axis of tooth until tip is located well above the apex of the second premolar.

Anterior Superior Alveolar

27 gauge long needle
Area of Insertion: Height of the mucobuccal fold anterior to the canine eminence
Advance Needle: Pathway parallels the long axis of the canine following the contour of the maxilla
Angle needle from insertion point to point of deposition above the apical area of
canine at the height of canine fossa.

Palatal Anesthesia
Nasopalatine
27 gauge short needle
Area of Insertion: Palatal mucosa just lateral to the incisive papilla
Advance Needle: At a 45 toward the incisive papilla, slowly toward incisive foramen until bone is
gently contacted. Depth of penetration = 5mm.

Greater Palatine
27 gauge short needle
Area of Insertion: Soft tissue slightly anterior to the greater palatine foramen
Locate greater palatine foramen by placing a cotton swab at the junction of the
maxillary alveolar process & the hard palate in the region of the maxillary first molar
& palpate firmly posteriorly until the swab falls into the palatine foramen
(usu. distal to the maxillary second molar)
Advance Needle: From the opposite side of the mouth with the needle approaching the injection site
at a right angle. Slowly advance until palatine bone is gently contacted. Depth of penetration is usually
less than 10 mm.

Anterior Middle Superior Alveolar

27 gauge short needle
Area of Insertion: Hard palate at the junction of the alveolar process and the maxilla intersecting the
contact between the first and second premolars.
Advance Needle: Orientation of the syringe should be from the contralateral premolars and held at
45 angle to the palate. Advance the needle 2mm/4-6 seconds until contact bone.

Mandibular Anesthesia
Inferior Alveolar
27 gauge long needle
Area of Insertion: Apex of pterygomandibular triangle approximately 7-8mm above the occlusal plane
Advance Needle: Approach from contralateral side, syringe barrel over molars, parallel to and 7-8mm above
occlusal plane. Advance until bone is contacted. Depth of penetration 2/3 to 3/4 length of a long needle.
Incisive
27 gauge short needle
Area of Insertion: Muccobuccal fold at or just anterior to the mental foramen
Advance Needle: New approach from anterior, with needle almost parallel to occlusal plane. Advance
the needle slowly until mental foramen is reached. Depth of penetration is 5-6mm. Apply firm pressure
over injection site for a minimum of 2 minutes afterward.
Long Buccal
27 gauge (long or short)
Area of Insertion: Buccal fold just distal & buccal to most posterior mandibular molar.
Advance needle parallel to the occlusal plane, holding tissue taut to avoid touching bone prior to 3-4mm insertion
 Local Anesthesia Resources

Mandibular Anesthesia

http://www.youtube.com/watch?v=IlMWadJs_r8

http://onlinelibrary.wiley.com/doi/10.1111/j.1834-
7819.2011.01312.x/full

Maxillary Anesthesia

https://www.youtube.com/watch?v=7tcgCPGV4kk

Summary of Techniques:

http://www.pitt.edu/~regional/Dental%20Blocks/dental%20block
s.htm

Research Articles:

http://jada.ada.org/article/S0002-8177(14)63748-X/fulltext

http://jada.ada.org/article/S0002-8177(14)63749-1/fulltext

http://jada.ada.org/article/S0002-8177(14)63750-8/fulltext

http://jada.ada.org/article/S0002-8177(14)63751-X/fulltext