LOCAL

ANESTHESIA April 15

AND
INJECTION
TECHNIQUE 2009
Local anesthetics cause a reversible
loss of sensation due to the transient
inhibition of periapical nerve
conduction. Their mechanism of
action can be summarized as follows:
Ca+ forms a complex with
phospholipids of the cell membrane,
and exerts a regulatory effect on
active transport of Na+ across the cell
membrane. Local anesthetics
competitively displace Ca+ from
nerve membranes, thus interfering
with the rapid, transient increase in
Na+ permeability that occurs when a
threshold potential is reached. Local
anesthetics interfere with both the
initiation and conduction rate of
action potentials.
 Local anesthetics cause a reversible loss of sensation due to the transient
inhibition of periapical nerve conduction. Their mechanism of action can be
summarized as follows: Ca+ forms a complex with phospholipids of the cell
membrane, and exerts a regulatory effect on active transport of Na + across the cell
membrane. Local anesthetics competitively displace Ca+ from nerve membranes,
thus interfering with the rapid, transient increase in Na+ permeability that occurs
when a threshold potential is reached. Local anesthetics interfere with both the
initiation and conduction rate of action potentials.

Anesthetic molecules have three basic parts:

Lipophilic aromatic residue

Hydrophilic amino group
Intermediate hydrocarbon chain

Local anesthetics are weakly basic solutions and are poorly soluble in water.
They are combined with HCl acid to form hydrochloride salts, which increases
water solubility. When in solution, two forms of anesthetic exist in equilibrium
with each other: uncharged base (RN) and charged cation (RNH+). Both the free
base and cationic forms are necessary for anesthesia.

RNH+  RN + H+

The base (RN) is responsible for diffusion through nerve sheath. The cation
+
(RNH ) is responsible for binding at receptor site inside the cell membrane, and
lowering of Na+ permeability.

With inflammation and infection, the extraneural (tissue) pH drops (pH of

pus = 5.5), but the intraneural space pH remains 7.4. This shifts the tissue
equilibrium to the left, thus increasing the concentration of cation (to 99%) and
reducing the concentration of free base (to 1%). Consequently, there is much less
available base for penetration of the nerve sheath.

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 The dissociation constant (pKa) is the pH at which equal amounts of (RN)
and (RNH+) exists. The pKa of lidocaine = 7.9, and the pKa of mepivacaine = 7.6.
At a tissue pH of 7.4, ~ 40% of mepivacaine is in the base form, whereas only ~
25% of lidocaine is. Mepivacaine should be used for blocks or peripheral
infiltration of infective processes, because it has the lower pKa, and more of it stays
in the free base form in a low pH environment. Also, solutions having the lower
pKa have a faster the onset of action.

Some reasons anesthetics are ineffective: (1) low pH of tissues; (2) dilution
by blood and fluids; and (3) rapid absorption into the systemic circulation.

Metabolism of local anesthetics:

Amides - hydrolyzed in liver by microsomal enzymes, excreted in kidney
Esters - hydrolyzed in plasma by pseudocholinesterase, excreted in kidney

Articaine is classified as an amide with an ester linkage. Articaine is inactivated by ester

hydrolysis via plasma carboxyesterase to articainic acid. ~50% of articaine is metabolized by
liver microsome p450 isoenzymes to articainic acid. Septocaine® has a pKa of 7.8.

Ingredients of a 1.8 ml cartridge:

2% lidocaine with 1/100,000 epinephrine (e.g. Xylocaine®)

lidocaine hydrochloride 36 mg
epinephrine 0.018 mg
sodium metabisulfite 0.9 mg (antioxidant)
citric acid 0.3 mg (preservative)
sodium chloride 10.8 mg (preservative)

3% mepivacaine (e.g. Polocaine®)

mepivacaine hydrochloride 54 mg
sodium chloride 4 mg

0.5% bupivacaine with 1/200,000 epinephrine (e.g. Marcaine®)

bupivacaine 9 mg
epinephrine 0.009 mg
sodium bisulfite 0.9 mg
ascorbic acid 3.2 mg (antimicrobial)

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 sodium chloride 10.8 mg

Ingredients of a 1.7 ml cartridge:

4% articaine with 1:100,000 epinephrine (e.g. Septocaine®)
articaine hydrochloride 68 mg
epinephrine 0.017 mg
sodium chloride 2.72 mg
sodium metabisulfite 0.85 mg

Complications of local anesthetics:

Anesthetic toxicity may be due to either excess administration or excess
absorption of anesthetic or vasoconstrictor; an intravascular injection; or, an
allergy to one of the components (e.g. the preservative). Signs of toxicity initially
might include CNS excitement, followed by CNS depression. Respiratory
depression is the most common cause of death following local anesthetic overdose.
Patients should be given supplemental oxygen and basic life support. For healthy
patients, the maximum dose of 2% lidocaine without vasoconstrictor is 300 mg.
That equates to just over 8 cartridges. When using 2% lidocaine with 1:100,000
epinephrine, the maximum dose is 500 mg, or ~14 cartridges. If the patient
receives a vasoconstrictor overdose, tachycardia, palpitations, headache and/or
restlessness may occur. Vasoconstrictors are contraindicated in patients taking
MAO inhibitors. The maximum safe dose of epinephrine for healthy adults is 0.2
mg (11 cartridges). For cardiac patients, this is 0.04 mg (2 cartridges).
Epinephrine is metabolized quickly.

Toxicity: the first sign is CNS stimulation (talkative, apprehensive),

followed by CNS depression (reduced BP, reduced pulse, respiratory depression)

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Treatment:
Reassure patient, administer O2, and monitor vital signs
IV diazepam for convulsions
For post-seizure depression - airway, O2
Neosynephrine 1% (1/2 cc)
Seek medical assistance ASAP
Idiosyncratic: O2, reassurance

Allergy:
Treatment:
Mild (rash)
Benadryl 50 mg IM, consult
Immediate (rash)
Epinephrine 0.4 mg (1:1,000) IM stat
Benadryl 50 mg IM
Medical consult
Anaphylactic
O2
Epinephrine 0.4 mg (1:1000) IM stat
Maintain airway
Seek medical assistance ASAP
Benadryl 50 mg IM
Solu-Cortef 100 mg IM

MANDIBULAR BLOCK ANESTHESIA

The standard mandibular block is very effective for the production of

outstanding anesthesia in a high percentage (~80%) of cases. Additional nerves
from the mylohyoid, lingual or cervical plexus may be responsible for some of the
unsuccessful mandibular blocks, however. What should be done if nerve block or
infiltration anesthesia is ineffective? There are times when additional or
supplemental anesthesia is needed for refractory cases. Anesthetize again, using an
alternate nerve block technique, infiltrate on the lingual side of the alveolus, or
apply intraligamentary (“PDL”), direct intraosseous (e.g. Stabident or X-tip) or

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intrapulpal techniques. Remember, PDL anesthesia is essentially an intraosseous
injection method.

GOW-GATES INJECTION
The conventional mandibular injection does not always work, due to the
presence of small branches of the main inferior alveolar nerve trunk, which depart
proximal to the area of the lingula and pass via other routes to the mandibular
teeth. The Gow-Gates injection bathes the common trunk of the inferior alveolar,
buccal and lingual nerves in the vicinity of the condyle, prior to their branching.
Gow-Gates claims a success rate of 100% and Malamed claims 97% success with
this technique; however, Montagnese et al. (J Endodon 1984) had only 35%
success in cases of irreversible pulpitis.

The technique aims for the lateral aspect of the condylar neck and includes:

1. Place patient in supine position

2. Patient should extend neck and open mouth wide
3. Place barrel of syringe over corner of mouth on opposite side
4. Needle will penetrate just distal to maxillary 2nd molar, at height
of palatal cusp
5. Aim needle toward tragus of ear, parallel with angulation of face
6. Advance needle until bone is contacted; the average depth is 25mm
7. Withdraw 1mm and inject at base of condylar neck
8. Patient should keep mouth open for 30 seconds, to bathe the nerve
trunk

AKINOSI INJECTION

A second alternative to the standard inferior alveolar injection is the Akinosi

block injection. This is a closed mouth injection and may be needed in a patient
who presents with limited opening, due to trismus, infection, or trauma. It affects
both motor and sensory nerves, so once anesthesia is achieved, some trismus
usually resolves.

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SECOND DIVISION BLOCK ANESTHESIA

The entire distribution of the second division of the trigeminal nerve

(maxillary or V2 nerve) can be anesthetized by one of two techniques. The first is
described as the high tuberosity technique. This technique is similar to the
posterior superior alveolar nerve injection, with the exception that a long (1-¼
inch), 25 or 27-gauge needle is inserted in an upward and inward direction to a
depth of ~30 mm. 2-4 ml of solution should be slowly injected.

The second technique is the greater palatine canal technique. The greater
palatine foramen, which opens into the greater palatine canal, is situated between
the second and third maxillary molars, ~1 cm toward the midline of the palate,
from the palatal gingival margin. The tissue over this area should be anesthetized
by local infiltration. A syringe with a 1-¼ inch (32 mm), 27-gauge needle is used
to approach the greater palatine foramen from the opposite side. When the
foramen is located, the needle is passed very slowly into the canal to within 2-3
mm of the hub. 2 ml of solution should be injected slowly in this area. Do not
force the needle on advancement. If resistance is met, withdraw slightly, redirect,
and again advance very slowly.
Great caution should be used with both techniques, and they should be used
when other techniques have failed to achieve anesthesia or are inappropriate: e.g.
when regional block anesthesia is required or infiltration anesthesia is
contraindicated due to cellulitis.

INTRAOSSEOUS ANESTHESIA
The intraosseous approach to anesthesia is not a new technique, but has had
a resurgence of interest in recent years. Popularity has paralleled the marketing of
specific devices to aid in performing this type of injection, most notably the
Stabident system. Because an intraosseous approach delivers anesthetic into a
very vascular area of medullary bone, some concern has been raised as to the
systemic effects of this injection. It appears the effects are transient, and not a
danger to healthy individuals. It is probably prudent to use 3% mepivacaine in any
individual who would be sensitive to epinephrine, such as patients who take
particular medications, or have cardiac problems or uncontrolled hyperthyroidism.
Most recently, another company has introduced a device, the X-tip, which adds a
guide sleeve (cannula) component. This remains in the bony channel to facilitate

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insertion of the injection needle. In response to this improvement, Stabident now
offers a guide sleeve with its Alternative Stabident.

INTRAPULPAL ANESTHESIA

Anesthesia is produced by strong back-pressure, which is essential for

success, and not as a direct result of the anesthetic solution used. Injection through
a small pulpal exposure site or wedged into individual canals will generally be very
effective.

LONG ACTING LOCAL ANESTHETICS

Long acting local anesthetics have many uses in dentistry, but have their
greatest applications in endodontics and oral surgery. One agent has become
popular in recent years: 0.5% bupivacaine with 1:200,000 epinephrine
(Marcaine). Marcaine is structurally similar to mepivacaine.

The increased potency of long acting local anesthetics is related to their greater lipid
solubility. Their long duration of action is related to increased protein binding; thus, long acting
anesthetics have a higher affinity for the nerve membrane. Local anesthetic effects may last up
to 8-10 hours after administration. Their use is excellent for significant acute apical periodontitis
and for post-surgical management.

Advantages of long acting local anesthetics include:

Less vasoconstrictor is administered

Longer duration of anesthetic effect
Very gradual return of sensation (claimed to be almost analgesic in effect)

The maximum, adult safe dose of Marcaine with epinephrine is 90 mg (10

cartridges of 0.5% bupivacaine with 1/200,000 epinephrine).

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STUDY QUESTIONS FOR 2006 ORAL EXAMINATION:

While a neuron rests, Na+ and Cl¯ reside outside of the cell membrane, and
K+ resides inside. The sodium pump maintains the resting potential by pumping
Na+ from inside to outside. When a stimulus of sufficient intensity is created, Na +
rapidly moves in while K+ leaves, resulting in a depolarization of the nerve
membrane, and an action potential, which propagates along the nerve membrane.

LOCAL ANAESTHETIC TECHNIQUE

For dental anaesthesia, the neuroanatomical focus is the fifth cranial nerve,
also known as the trigeminal nerve. This nerve has three divisions - the ophthalmic
division (V1), the maxillary division (V2) and the mandibular division (V3). The
maxillary dentition receives innervation from V2, and the mandibular dentition
receives innervation from V3.

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The maxillary nerve enters the pterygopalatine fossa and branches into three major
sections: the ganglionic branches, the zygomatic nerve and the posterior superior
alveolar nerve. The ganglionic branches travel to the pterygopalatine ganglion,
which in turn sends sensory, parasympathetic and sympathetic fibres back to the
maxillary nerve. The zygomatic nerve enters the orbit and travels along the lateral
wall. It bifurcates into two terminal branches, the zygomaticofacial nerve, which
supplies sensation to the cheek, and the zygomaticotemporal nerve, which supplies
sensation to the temple area. There is also a parasympathetic component to the
lacrimalgland.

The posterior superior alveolar nerve travels inferiorly on the infratemporal surface
of the maxilla, entering the maxillary sinus and eventually terminating in sensory
branches for the maxillary molars and their surrounding buccal gingiva, with the
possible exception of the mesiobuccal root of the first molar.

As the maxillary nerve continues, it enters the infraorbital groove and becomes the
infraorbital nerve. This nerve gives rise to the middle and anterior superior alveolar
nerves. The middle superior alveolar nerve supplies sensation to the mesiobuccal
root of the maxillary first molar, the premolars and the associated buccal gingival.
However, this nerve is not present in all people; if the nerve is absent, these areas
are innervated by the posterior and anterior superior alveolar nerves. The main
areas of sensory innervation for the anterior superior alveolar nerve are the cuspid,
and central and lateral incisors and the buccal gingiva in that area.

The infraorbital nerve continues and eventually passes through the infraorbital
foramen onto the face, supplying the lower eyelid, the side of the nose and the
upper lip.

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11
The mandibular nerve leaves the base of the skull through foramen ovale. The first
branch from the main trunk is the nervous spinosis, which runs superiorly through
the foramen spinosum to supply the meninges. The next branch is the first motor
nerve, which supplies the medial pterygoid muscle. Inferior to that branch, the
mandibular nerve splits into an anterior trunk and a posterior trunk. The anterior
trunk is both sensory and motor. The sensory trunk is the long buccal nerve, which
supplies the buccal soft tissue distal to the first molar. The motor component
supplies the masseter, temporal and lateral pterygoid muscles. The posterior trunk
sends off the auriculotemporal nerve that gives sensory perception to the side of
the head and scalp and sends twigs to the external auditory meatus, the tympanic
membrane and the temporomandibular joint. The posterior trunk then almost
immediately divides into the lingual nerve and the inferior alveolar nerve. The
lingual nerve supplies the anterior two-thirds of the tongue and the lingual surface
of the mandibular gingiva. The mandibular nerve sends a branch to the mylohyoid
muscle and the anterior belly of the digastric muscle and then enters the
mandibular canal. This nerve gives sensation to the mandible, the buccal gingiva
anterior to the first molar, the lower lip and the pulps of all the mandibular teeth in
that quadrant.

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One of dentistry's most difficult challenges is consistently anaesthetizing the
mandibular dentition. A conventional mandibular block has a failure rate of at least
15% to 20%. There are a number of possible reasons for this phenomenon, one of
which is accessory innervation (see "The Reasons For Incomplete Anaesthesia",
below).

Dental injection techniques include the inferior alveolar nerve block, the Gow-
Gates mandibular block, the Vazirani-Akinosi closed mouth mandibular block,
intraosseous injections, periodontal ligament injections and various adjunctive
techniques.

The Inferior Alveolar Nerve Block

The inferior alveolar nerve block is the most widely used technique for blocking
the hemimandible. However, as mentioned above, due to neuroanatomical and
skeletal variations, there is a failure rate of 15% to 20% in achieving complete
anaesthesia. The advantages and disadvantages for this technique are listed in the
table below.

Advantages Disadvantages

 Practitioner acceptance  Area of injection is vascular; 10 -

 Faster onset than higher
blocks
 Bony landmark
15% chance of positive aspiration
 Unlikely to anaesthetize accessory
nerves
 Unlikely to anaesthetize long
buccal nerve
 Difficult to see landmarks in some
patients (e.g., macroglossia)

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The landmarks for this injection are as follows:
1. the coronoid notch (the greatest depression on the anterior
border of the ramus), also called the external oblique ridge
2. the internal oblique ridge
3. the pterygomandibular raphe
4. the pterygotemporal depression
5. the contralateral mandibular bicuspids

Technique
1. Palpate the anterior ramus border at the coronoid notch.

2. Slide the finger or thumb posteriorly and medially until a ridge of bone is palpated. This
is the internal oblique ridge.

3. Insert the needle into soft tissue in the pterygotemporal depression, which is halfway
between the palpating finger or thumb and the pterygomandibular raphe.

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 4. Approximate the height of the injection by the middle of the palpating fingernail or
thumbnail.
5. Ensure that the barrel of the syringe is located over the contralateral mandibular
bicuspids.
6. Insert until bone is contacted, and then withdraw ~1 mm. The depth of insertion for the
average-sized adult is approximately 25 mm.

7. Aspirate.
8. Inject a full cartridge.

Onset and duration

 Onset for hard tissue anaesthesia is 3 to 4 minutes.
 Duration for hard tissue anaesthesia is 40 minutes to 4 hours, depending on the type of
local anaesthetic used and whether a vasoconstrictor is used.
 It is unlikely that the long buccal nerve will be anaesthetized.

The Gow-Gates Mandibular Block

In 1973, Dr. George Gow-Gates published an article describing an alternative technique for
blocking the mandible. The advantages and disadvantages of this technique are listed in the table
below.

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Advantages Disadvantages

 Perceptible end point (bone)  Mouth wide open

 Fewer blood vessels at this level,  Must use extraoral landmarks, which may
therefore less chance of positive increase the difficulty of this procedure
aspiration
 Long buccal nerve anaesthesia likely
 Possible longer duration of anaesthesia
 Less chance of anaesthetizing
accessory nerves

The landmarks for this injection are as follows:

10 mm above the coronoid notch
the internal oblique ridge
the pterygomandibular raphe
the neck of the condyle
the contralateral mandibular bicuspids
an imaginary line from the corner of the mouth to the tragal notch of the ear
(extraorally).

Technique
1. Ask the patient to open his or her mouth wide.
2. Palpate the coronoid notch and slide the finger or thumb to rest on the internal oblique
ridge.
3. Move the finger or thumb superiorly approximately 10 mm.

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4. Rotate the finger or thumb to parallel an imaginary line from the ipsilateral corner of the
mouth to the tragal notch of the ear.
5. Insert the needle at a point between the palpating fingernail and the pterygomandibular
raphe at the middle aspect of the fingernail.
6. Ensure that the barrel of the syringe is located over the contralateral bicuspids.

7. As the injection proceeds, ensure that the angle of the needle and syringe is parallel to the
imaginary line from the corner of the mouth to the tragus of the ear.

8. Insert until bone is contacted (at the neck of the condyle), which should occur at a depth
of approximately 25 mm. (Note: This is not a deeper injection, because the patient's

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 mouth is open wide and, as a result, the condyle has translocated anteriorly to provide a
target.)

9. Once bone is contacted, withdraw the needle tip 1 mm to prevent injecting into the
periosteum, which would be painful.
10. Aspirate.
11. Inject a full cartridge.

Onset and duration

 Onset for hard tissue anaesthesia is 4 to 12 minutes, with the anterior areas
taking the longest amount of time.
 The long buccal nerve will likely be anaesthetized.

The Vazirani-Akinosi Closed Mouth Mandibular Block

In 1960, S. Vazirani published a paper describing a closed mouth mandibular

block; however, it was not until 1977, when J.O. Akinosi published a paper on this
approach, that the technique gained popularity. The advantages and disadvantages
of this technique are listed in the table below.

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Advantages Disadvantages

 Can be used for patients with  Difficult to visualize depth of injection

trismus
 Can be used for patients with a
strong gag reflex
 Mouth is closed, so injection may be
less threatening to patient
 Possibly less pain, because tissues
are relaxed
 Good for macroglossic patients
 Difficult in patients with widely flaring
ramus
 Difficult in patients with pronounced
zygomatic ridge or internal oblique
ridge

The landmarks for this injection are as follows:

the maxillary buccal mucogingival line or root apices of the maxillary teeth
the coronoid notch
the internal oblique ridge
the occlusal plane

Technique
1. Prepare the needle and syringe by bending the needle approximately 15o to
20o. This bend accommodates for the flare of the ramus. Do not bend the
needle more than once when preparing.
2. Ask the patient to slightly open (a few millimeters) his or her mouth and
execute a lateral excursion toward the side that is being injected.
3. Palpate the coronoid notch and slide the finger or thumb to rest on the
internal oblique ridge.

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4. Move the finger or thumb superiorly approximately 10 mm.

5. Insert the needle tip between the finger and maxilla at the height of the maxillary buccal
mucogingival line. Orient the bend of the needle such that the needle looks as though it is
going laterally in the direction of the ear lobe on the injection side. The needle remains
parallel to the occlusal plane.

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 6.
7. After the needle has been inserted 5 mm, remove the palpating finger or thumb and use it
to reflect the maxillary lip to enhance vision.
8. Inject to the final depth of approximately 28 mm for the average-sized adult, therefore
visualizing 7 mm of needle remaining outside the tissue (if using a long needle).

9. Aspirate.
10. Inject a full cartridge.

Onset and duration

 Onset for hard tissue anaesthesia is 3 to 4 minutes
 There is an increased possibility of obtaining long buccal nerve anaesthesia
as compared to the inferior alveolar nerve block.

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Intraosseous Injections
With intraosseous injections, the local anaesthetic solution is deposited directly
into the cancellous bone surrounding the teeth being treated. These techniques can
be considered if one of the primary nerve blocks has failed. Early techniques for
delivering the local anaesthetic into the cancellous bone used a round bur to
perforate the cortical plate, with the drug then being injected through this hole.
Over the past 20 years, new and more effective devices have been introduced into
the marketplace. Two of the more common products are Stabident and the X-tip.
Each of these products uses a different technique, and the practitioner is
encouraged to follow specific instructions.

Advantages Disadvantage

 Immediate onset of anaesthesia  Short duration of anaesthesia

 No soft tissue (lip or tongue)
anaesthesia
 Can operate bilaterally in the
mandible
 Can anaesthetize a "hot" tooth
 Good approach for accessory
innervation
 High success rate
 Must limit volume due to increased
vascularity in the cancellous bone
 Difficult access to posterior mandible
 Anatomical limitations
 Some patients experience palpitations
 Cannot use in areas of periodontal
disease

Technique
1. Follow the specific instructions supplied with the delivery system.
2. Anaesthetize the soft tissue to ensure that the perforation of the cortical plate
is painless. Inject an infiltration of 0.2 mL to 0.3 mL of local anaesthetic into
the buccal fold near the area to be perforated.
3. Take a radiograph to ensure that there is enough bone at the perforation site
so that the periodontal ligament space or root surfaces will not be violated.
4. Perforate the bone using whichever device has been chosen. The site of
perforation is on the attached gingiva approximately 1 mm to 2 mm
coronally to the mucogingival line.
5. Negotiate the needle through the perforated bone into the cancellous space
and slowly inject 0.9 mL of local anaesthetic. This volume provides pulpal
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 anaesthesia for the teeth on either side of the perforation. The injection
should be done slowly, over about 45 seconds per 0.9 mL, to avoid
palpitations as much as possible.

Do not exceed one cartridge of intraosseous anaesthetic per appointment.

Anatomical limitations include inadequate bony space between the teeth, a cortical
plate of bone that is too thick to perforate, a low-lying maxillary sinus and a
horizontally impacted third molar. In addition, the technique cannot be used
between central incisors due to the lack of cancellous bone.

This technique should not be used on patients with cardiac disease.

Onset and duration

The onset of anaesthesia is immediate.
Duration for pulpal anaesthesia is 20 to 30 minutes if a vasoconstrictor is
used and significantly less than that if a vasoconstrictor is not used.

Periodontal Ligament Injection

In the periodontal ligament (PDL) injection, local anaesthetic is injected with

pressure into the PDL space. A number of devices are available to facilitate this
type of injection by providing the necessary pressure; however, this technique can
be done with a standard syringe. If using a standard syringe, the practitioner can
express three-quarters of the volume within the local anaesthetic cartridge to lessen
the pressure that has to be pushed against and to decrease the chance that the glass
cartridge will break.

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Advantages Disadvantages

 Immediate onset of  Patient may experience post-operative pain

anaesthesia
 No soft tissue anaesthesia
 Works well for "hot" teeth
 Good approach for accessory
innervation
 High success rate
 There is a transient decrease in pulpal blood
flow to the tooth
 Cannot be used in areas of periodontal disease
 Pressure is required to inject into the PDL space
 Multiple injections are required for multi-rooted
teeth (one injection per root)
 May not work on long roots (e.g., cuspids)

Technique
1. Anaesthetize the soft tissue to allow for a comfortable PDL injection. Inject an infiltration
of 0.2 mL to 0.3 mL of local anaesthetic into the buccal fold adjacent to the desired tooth.
2. Embed the needle into the PDL space.
3. Inject 0.2 mL per root.
4. Allow 10 seconds to pass to allow back pressure to dissipate and ensure that local
anaesthetic does not leak into the mouth upon removal of the needle.

Onset and duration

 The onset of anaesthesia is immediate.
 The duration of pulpal anaesthesia is highly variable and somewhat unpredictable.

Adjunctive Techniques
Other techniques and devices have been used and reported to provide some level of
either soft tissue or hard tissue anaesthesia.

Electronic dental anaesthesia is a technique wherein electrodes are fixed to

locations on the patient's face, and the patient is given controls that can send
stimuli from one electrode to the other. The theory is similar to that behind TENS
(transcutaneous electric nerve stimulation). The electrical signal seems to decrease
the patient's ability to perceive pain. Although these devices are no longer
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marketed, some dentists have reported success with them in situations where light
anaesthesia is required (e.g., deep scaling).

Also now available are ultrasonic scalers, through which the patient controls a
low-intensity DC current that goes through the scaler tip to the tooth. This stimulus
may be able to block the perception of mild pain. Further evaluation of these
devices is required.

Another device used by some practitioners is the jet injector, of which different
models are available. They can expel the local anaesthetic with such force and in
such a fine stream that it can penetrate soft tissue without a needle. The
disadvantage is that only enough volume can be expressed to anaesthetize the soft
tissue, and they may therefore be used for topical anaesthesia but not for pulpal
anaesthesia.

Reasons for Incomplete Anaesthesia

The reasons for incomplete local anaesthesia are as follows:

local anaesthetic pka - ph factors and tissue ph factors

needle-to-jaw size discrepancy
needle deflection
volume factors
skeletal and neuroanatomic variations
local anaesthetic or vasoconstrictor degradation
unco-operative patients

Local anaesthetic pKa - pH factors and tissue pH

factors
When a local anaesthetic is injected into tissue, two particles are in equilibrium: a lipophilic
(lipid-soluble) neutral particle and a positively charged hydrophilic (water-soluble) particle.
Initially, it is advantageous to have the greatest proportion possible of lipophilic particles,
because these particles can pass through the lipid membrane of the nerve. Once inside the nerve,
a new equilibrium is established, and a new set of hydrophilic particles form. These hydrophilic,
charged molecules work to stop the action potential inside the nerve.

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The practitioner can influence the ratio of lipophilic molecules to hydrophilic
particles to decrease the onset of anaesthesia. Three factors can affect this
equilibrium: the pKa of the local anaesthetic, the pH of the local anaesthetic and the
pH of the tissue in which the anaesthetic is being deposited.

The pKa of a local anaesthetic is defined as the pH at which half of the local
anaesthetic particles in equilibrium are neutral (lipophilic) and half are charged
(hydrophilic). For example, if a local anaesthetic had a pH of 7.4 and was injected
into normal tissue, which also has a pH of 7.4, there would be equal amounts of
both types of particles. The anaesthic would therefore be likely to have a relatively
short onset of action due to the large initial proportion (50%) of lipophilic
molecules able to cross the lipid nerve membrane. Unfortunately, all local
anaesthetics have pKa values higher than 7.4. As a result, the injection of a local
anaesthetic shifts the equilibrium toward the hydrophilic molecules, with
proportionately fewer available lipophilic particles. Practitioners are forced to live
with the onset times that result from these greater-than-7.4 pKa values. The extreme
example in this case is procaine (Novocain), which has a pKa value of 9.1. This
value results in a very long onset of action time, which is one of the poor qualities
of ester local anaesthetics that have led to their depopularization as injectable local
anaesthetics in dentistry. Therefore, the general rule of thumb is that the higher the
pKa of the local anaesthetic, the longer its onset of action due to the fewer lipid
soluble particles initially available to cross the nerve sheath. More simply put,
higher pKa equates to decreased potency.

A factor that dentists can influence is pH. There are two separate issues with
respect to pH: the pH of the tissues where the local anaesthetic is being injected
and the pH of the local anaesthetic itself. As mentioned above, normal tissue pH is
7.4, but if there is an infection in the area of injection, the pH will be lower (in the
acidic range). The effect of this infection is similar to the high pKa of the local
anaesthetic; that is, it shifts the equilibrium toward the charged hydrophilic side of
the equation and thereby lessens the initial amount of lipophilic particles available.
This equilibrium, in turn, increases the time to onset of anaesthesia. If the infection
is severe and the pH of the tissue therefore quite low, few lipophilic particles will
be available, and the local anaesthetic might not work at all. Most dentists have
experienced this failure of anaesthesia when attempting to anaesthetize a "hot"
tooth or when trying to anaesthetize an area of severe periodontal disease.

The local anaesthetic itself can cause another pH problem. Local anaesthetics with
a vasoconstrictor contain the preservative sodium metabisulphite. This preservative
is quite acidic, and in high concentrations it can lower the overall pH of the local

26
anaesthetic solution to 4 or 5. The higher the concentration of the vasoconstrictor,
the more preservative is required and the lower the pH. Thus, the solution injected
into the tissues can be quite acidic.

Consider the following example: A practitioner attempts a mandibular block using

a local anaesthetic with 1:100,000 epinephrine. While the practitioner is working
on a tooth, the patient feels pain. The practitioner administers another block with
the same solution, but the patient still perceives pain. If the practitioner gives yet a
third block, the pH in the pterygomandibular triangle will be so acidic that the
equilibrium will be shifted well away from the lipophilic particles and there will be
no opportunity for local anaesthetic molecules to cross into the nerve. A block will
never be achieved in this situation regardless of how much vasoconstrictor-
containing local anaesthesia is administered. It is recommended that if, after two
attempts at a block, there is still incomplete anaesthesia, the practitioner try a
vasoconstrictor-free solution injected into a slightly different location in the
pterygomandibular triangle. This injection should increase the pH in the area and
possibly even buffer it somewhat, because a "plain" solution has a more basic pH.
There should then be enough lipophilic particles to cross the lipid nerve membrane.

Needle-to-jaw size discrepancy

In dental practice, two popular lengths of needles are available for routine injections. The short
needle is approximately 25 mm or one inch long, and the long needle measures approximately 35
mm or 1 5/8 inches long.

Short needles cannot be recommended for mandibular block injections in adult patients. The
depth required for a mandibular block for the average-sized adult is 25 mm. Thus, to reach the
injection end point with a short needle, the practitioner must inject to the hub. This practice could
cause complications in the unlikely event of needle breakage. Also, it is easier to lose one's
orientation and angulation, which could mislocate the injection. Furthermore, if the patient is
larger than average, the final depth will not be achieved unless the practitioner pushes the needle
into the tissues beyond the hub. If the practitioner is performing a Vazirani-Akinosi mandibular
block, which has an average depth of 25 mm to 27 mm, it becomes even more difficult to
achieve the final depth.

Long needles afford the practitioner the ability to observe the length of needle that is remaining
outside the tissues once the final depth has been achieved. For the average-sized adult, the
practitioner would observe 10 mm of needle remaining outside the tissues once the final position
has been attained using a long needle for the conventional mandibular nerve block. Simply put,
long needles may increase success rates in achieving mandibular blocks.

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Needle deflection
When a needle is inserted into tissue, it deflects due to the density of the tissue pushing against
the bevel of the needle. The deeper the needle is inserted and the thinner the needle (the higher
the gauge), the more the needle deflects. The deflection occurs such that the needle is pushed
away from the bevel. A study by Aldous first demonstrated this phenomenon. Using a tissue
medium of hydrocolloid and hot dogs, Aldous demonstrated that a 30-gauge needle inserted to a
depth of 25 mm would deflect 4 mm, a 27-gauge needle would deflect 2 mm and a 25-gauge
needle would deflect 1 mm. Repeat studies by other scientists using human tissue and
radiography have yielded similar results. Because a 4-mm deflection is enough to mislocate any
block injection, there is valid reason for using more stable, lower-gauge needles.

The orientation of the bevel is important not only with respect to needle deflection. The
practitioner may wish to know where the bevel is once the needle has been inserted into tissue.
For example, when infiltrating, it is customary to face the bevel toward bone to avoid scraping
the periosteum. Also, when performing a Vazirani-Akinosi block, the practitioner may wish to
face the bevel toward the patient's midline to have the needle deflect laterally, toward the nerve.
There are needles on the market that have markings on the hub, indicating the position of the
bevel.

Volume factors

Dentists usually rely on one cartridge of local anaesthetic to provide profound anaesthesia to
most areas. Nonetheless, a number of factors can contribute to inadequate volume of local
anaesthesia and the resulting need to inject more than one cartridge.

28
The first factor is time. When a mandibular block is given, the practitioner must wait 3 to 4
minutes to allow the anaesthetic to completely bathe the nerve, thus totally blocking it. If a
procedure is commenced before the time required for complete anaesthesia, the patient will
experience discomfort, as the full volume of anaesthetic will not have had a chance to
anaesthetize the whole thickness of the nerve.

Second, there is an anatomical structure that can physically stop the local anaesthetic from
travelling to the inferior alveolar nerve. If local anaesthetic is deposited too far medially away
from the inferior alveolar nerve, it is blocked from travelling laterally by the sphenomandibular
ligament and its associated fascia. This ligament runs from the sphenoid process to the lingula,
and attached to it is a fascia that fans out in a sagittal direction. Local anaesthetic cannot cross
this barrier, and it is therefore crucial to inject lateral to the ligament. Otherwise, the patient will
experience incomplete anaesthesia or maybe even no anaesthesia at all.

Another anatomical factor to consider is the vasculature. If the local anaesthetic is deposited into
a vessel, no anaesthesia is obtained. It is recommended to use a wider-lumen (lower-gauge)
needle to increase the likelihood of success in obtaining a positive aspiration. For example, a 25-
gauge needle offers a much more reliable indicator of positive aspiration than does a 30-gauge
needle, which offers a very poor indicator of positive aspiration.

29
A fourth factor, also anatomical, is the thickness of the nerve. The inferior alveolar nerve, at the
level of the conventional mandibular nerve block, is thinner than the core mandibular nerve,
which is approximated in the Gow-Gates block. This thicker nerve requires a longer onset time
for complete infiltration; the conventional mandibular nerve block takes 3 to 4 minutes to
complete anaesthesia, compared to the 10 to 12 minutes for the Gow-Gates block. The other
important reason for the longer onset time is simply the longer distance the drug has to travel in a
Gow-Gates versus a standard block. The practitioner could consider an intraosseous or PDL
injection to minimize the onset of anaesthesia.

A fifth factor to consider is the actual volume of the local anaesthetic. Some patients require
more than one cartridge of local anaesthetic to anaesthetize the mandible. Accessory innervation
(see below under "Skeletal and neuroanatomic variations"), thicker nerves and larger patients
may necessitate more anaesthetic. For such patients, a practitioner may decide to give two
cartridges of local anaesthesia in slightly different locations - for example, one in the location of
the conventional block, and one in the area of the Gow-Gates block. The extra dose maximizes
the volume and saturates the pterygomandibular space with anaesthetic.

Skeletal and neuroanatomic variations

A variety of anatomical variances can lead to a missed block if not considered in landmarking.
Skeletal factors, such as class of occlusion and the width of the ramus, change the location of the
lingula relative to the intraoral landmarks. In addition, a ramus that flares widely from the
midline requires the syringe to be located more over the contralateral molars when blocking the
hemi-mandible, while a ramus that is more parallel to the mid-sagittal plane requires the syringe
to be more over the contralateral cuspids.

Another crucial skeletal anatomical variant is the width of the internal oblique ridge. It is on this
ridge that the practitioner's finger must rest for all mandibular block procedures, including the
conventional, the Vazirani-Akinosi and the Gow-Gates. If the patient has an exceedingly wide
internal oblique ridge and the practitioner's finger is not resting on this ridge of bone, it is very
difficult to negotiate the needle past this bony ridge to approach the inferior alveolar nerve. This
nerve is located on the medial aspect of the ramus behind the large ridge. Palpating a wide
inferior alveolar ridge is also cause to rotate the syringe more posteriorly, toward the
contralateral molars.

A final skeletal anatomical factor is the position of the mandibular foramen. The location of this
foramen can vary both in its anterior - posterior position and its inferior - superior position.
Blocks given more superiorly, for example, the Gow-Gates block, may in part be more
successful due to the increased chance of being superior to this foramen. Therefore, the local
anaesthetic is not being deposited inferior to where the nerve enters the mandible (which would
result in incomplete anaesthesia).

Dissection studies have shown that both the mylohyoid nerve and the mandibular nerve can send
accessory nerves through various locations in the pterygomandibular triangle. These accessory
nerves can enter the mandible in various lingual locations on the ramus or on the alveolar ridge.

30
The mandibular nerve has been shown to send accessory nerves that can enter the mandible
through foramina in the retromolar area on the coronoid process. The mylohyoid nerve can send
branches through foramina located anywhere on the lingual aspect of the mandible and thus
directly supply accessory innervation to any of the mandibular teeth. Either type of accessory
innervation could cause a patient to experience incomplete anaesthesia with a conventional
mandibular nerve block. Correcting the lack of complete anaesthesia is possible through a
number of different techniques. First, a Gow-Gates block can be given; because this block is
more superior in the pterygomandibular triangle, it is more likely to be superior to the location of
where the accessory nerve leaves the core nerve. Second, 0.4 mL to 0.5 mL of local anaesthetic
can be injected into the retromolar area or lingual to the tooth being treated. This lingual
injection would occur on the vertical wall of the mandible in the area of the unattached gingiva.
The practitioner should be careful to avoid the floor of the mouth, where the submandibular
salivary gland exists.

Local anaesthetic or vasoconstrictor degradation

All local anaesthetic cartridges have an expiry date on their label. This date tells the practitioner
the product's shelf life from the time of manufacturing to the time when a certain number of the
anaesthetic or vasoconstrictor molecules have degraded to a degree that the product may be less
effective. Local anaesthetic molecules are relatively stable and degrade very slowly. As a result,
the shelf life of a local anaesthetic depends mostly on the stability of the vasoconstrictor. For this
reason, sodium metabisulphite is used as a preservative or stabilizer for the vasoconstrictor
molecule. A number of factors can lead to the premature breakdown of an anaesthetic and the
vasoconstrictor within a cartridge, including extreme temperatures, excessive light and oxygen
exposure. To maximize the shelf life of the contents inside the cartridge, the local anaesthetic
molecule should be stored at room temperature away from sunlight and room light. Dental
offices are unlikely to experience temperature extremes, but consideration should be given to
how the local anaesthetic was delivered to the office. Local anaesthetics can easily freeze or
overheat if left in a delivery truck during seasonal extremes. These temperature variations can
lead to the premature degradation of the molecules in the cartridge.

Autoclaving or repeatedly using cartridge warmers will decrease the shelf life of the contents of
the local anaesthetic cartridge.

Local anaesthetics should not be purchased for stockpiling in such amounts that the stale date
arrives before the solution can be utilized.

Unco-operative patients
Incomplete anaesthesia is not only frustrating for the practitioner but is also uncomfortable at
best or devastating at worst for the patient. Many dental-phobic patients report a prior dental visit
in which they experienced pain. When these patients next attend a dental office, they do so with
great trepidation. It can be very difficult for them to walk through the front door of the dental

31
office, let alone open their mouths wide to allow for dental treatment. For this reason, profound
anaesthesia can be difficult to obtain with dental-phobic patients. Many of these patients may
have had other reasons for incomplete anaesthesia, and now, to compound the problem, they are
unwilling to open their mouths wide enough for the practitioner to be able to visualize the
landmarks necessary to achieve a successful injection.

In such situations, the practitioner must strive to elicit the patient's co-operation through
reassurance and explanation. For example, the practitioner could say, "Please lift your chin up
and open your mouth wide. That will really help the anaesthetic to work." If the patient's anxiety
is strong enough that it impedes their ability to co-operate, conscious sedation such as nitrous
oxide and oxygen may be considered.

Other Issues
Needle length and gauge
The three standard dental needle lengths are long (~35 mm), short (~25 mm) and ultra-short (~12
mm). The exact measurements vary slightly. In general, it is suggested that long needles should
be used for deeper injections such as blocks in the mandible to improve accuracy (see "Needle-
To-Jaw Size Discrepancy", above, under "Reasons for Incomplete Anaesthesia"). Short needles
can be used elsewhere, and ultra-short needles may be useful for a PDL injection.

The three standard dental needle gauges, or thicknesses, are 25-gauge, 27-gauge and 30-gauge.
The choice depends on two main factors. First, the thicker the needle, the more stable it is and
the less it deflects when pushed into tissue; therefore, a practitioner may decide to use thicker
needles on heavier-set individuals. Second, neither 27-gauge nor 30-gauge needles are reliable
aspirators of blood; therefore, whenever the practitioner is injecting into an area where there is
the possibility of entering a blood vessel, a 25-gauge needle should be used. The patient will not
be able to discern the difference between the prick of a 25-, 27- or 30-gauge needle. One needle
will not hurt more than another. The key to reducing pain during injection, regardless of the
needle gauge, is to inject slowly.

Burning on injection
A burning sensation on injection may occur for two reasons. First, local anaesthetics with a
vasoconstrictor are acidic because of the preservative required for the vasoconstrictor. This
acidity can cause the anaesthetic to burn when it is injected into tissues. As the cartridge ages and
approaches the expiry date, the vasoconstrictor begins to break down, resulting in even a lower
pH and therefore even more burning on injection. Second, if cartridges are immersed in
sterilizing solution and the solution seeps into the cartridge, the sterilizing solution can cause a
burning sensation upon injection.

The likelihood of a burning sensation can be minimized by using fresh anaesthetics with little or
no vasoconstrictor and by injecting slowly.

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Cartridge warmers
Cartridge warmers are used with the hope that increasing the temperature of the local anaesthetic
will decrease the amount of pain felt by the patient during the injection. There is no scientific
evidence that warming a local anaesthetic cartridge from room temperature (the temperature of
the anaesthetic while stored) to body temperature changes the amount of discomfort experienced
by the patient. In fact, even if the anaesthetic is warmed, it will approach the temperature of the
needle (room temperature) as it is pushed through and into the tissues. As well, repeatedly
heating or overheating the cartridge results in degradation of the vasoconstrictor, thereby
decreasing the shelf life of the product, decreasing the duration of local anaesthesia and, in the
case of overheating, causing more pain during injection.

Summary
Injecting local anaesthetics can become routine for dental practitioners because of the high
efficacy and wide safety margin of these products. Nonetheless, there are instances when these
drugs do not work or when they must be used with caution. This section has attempted to
highlight important issues about local anaesthetic use to aid practitioners in making their local
anaesthesia practice as effective and as safe as possible.

References:
1. Bennet CR, 1974 Monbieim’s local anesthesia and pain control in dental practice, 5 th.ed,
St Louis, Mosby.
2. Malamed SF, 2004 Handbook of Local Anesthesia, 5th.ed, Mosby.
3. Malmed SF, 2003 Sedation: a guide to patient management,ed 4, St Louis. Mosby
4. Malmed SF, 1980 Handook of local anesthesia, St Louis, Mosby.
5. Prescribing information: Septocaine, Septodont, Inc,www.spetodontusa.com
6. Clinicians guide to dental products and techniques, Setocaine, 2001 June, CRA
Newsletter.
7. Malmed SF, 2004 Handbook of Local Anesthesia, 5th.edn, Mosby.
8. USP DI Updaten On-Line, United States Pharmacopeial Convention, Inc.,www.us.org. .
9. Clinician guide to dental products and techniques, Septocaine, CRA Newsletter, June,
2001.
10. Prescribing information: Scandanest, Septodont, Inc,www.septodontusa.com.
11. Prescribing information: Ravocaine and Navocaine with Levophed, New York 1993,
Cook-waite, Sterling Winthrop.
12. Akinosi JO. A new approach to the mandibular nerve block. Brit J Oral Surg 1977-
78;15:83-87.
13. Aldous JA. Needle deflection: A factor in the administration of local anesthetics. JADA
1968;77(3):602-4.

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14. Davidson M. Bevel-oriented mandibular injections: Needle deflection can be beneficial.
Gen Dent 1989;36(3):410-12.
15. Gow-Gates G. Mandibular conduction anesthesia: A new technique using extraoral
landmarks. Oral Surg 1973 Sept.
16. Hochman M, Friedman M. In vitro study of needle deflection: A linear insertion
technique versus a bi-directional rotation insertion technique. Quintessence Int 2000
Jan:33-39.
17. Kaufmann E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. JADA
1984 108:205-8.
18. Roda R, Blanton P. The anatomy of local anesthesia. Quintessence Int 1994;25(1):27-38.
19. Vazirani S. Closed mouth mandibular nerve block: A new technique. Dent Digest 1960
66:10-13.

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