Dental local anesthetics

Dental local anesthetics

Dental local anesthetics are the numbing agents dentist use to ensure local anesthesia of teeth and gums in order to do our work. There are several types of anesthetic we can use and several techniques from which we can choose to deliver it.

Dental local anesthetics options

Dental anesthetics are either amide or ester. Many contain the vasopressors epinephrine or levonordefrin and thus will have sodium metabisulfite preservative. Levonordefrin is a sympathomimetic amine we use as a vasoconstrictor and epinephrine restricts arteries in skin and tissue as part of it’s fight or flight response. Both vasopressors sting.

Amides

  • Lidocaine – best for pregnancy
  • Articaine
  • Mepivicaine
  • Bupivicaine – causes inflammation so give some NSAIDs
  • Prilocaine

Esters – this class creates PABA metabolite which can be a source of allergy

  • Benzocaine – this can cause methemoglobinemia

Dental local anesthetics historyDental local anesthetic duration of action

The duration of action of a dental anesthetic varies due to

  • Volume
  • Lipid solubility
  • Protein binding – Better the binding the longer it acts

Table of dental local anesthetics protein binding ability

  • Diffusion away from site
  • Type of injection – blocks last longer than infiltration
  • Tissue type – soft tissue lasts longer than pulpal.

Table of dental local anesthetics duration of action

Dental local anesthetic tips

Lidocaine – use 1:200k instead of 1:1ook since same effectiveness and less risk, use 1:50k for hemostasis. We consider lidocaine and prilocaine the safest local anesthetic for use during pregnancy.

Bupivicaine – only long lasting if block and in soft tissue NOT for pulpal if infiltration. Highest lipid solubility so can work at very low concentrations.

Image of dental local anesthetics lipid solubility.

Mepivicaine – no epi last 20-40 pupal  2-3 h soft tissue.  Lowest pKa tso better for tissue with inflammation, infection, and re-injection.  Shorter onset and longer duration than lidocaine.  More effective IAN for teeth getting RCT with apical periodontists Visconti JOE 2016

Prilocaine

Prilocaine is short acting, only lasts 40-60 pulpal if block and only  5-10 if infiltrate. It is the least painful during injection so some will use first. Prilocaine works well on hard to anesthetize patients.
Prilocaine w epi  – similar lido and mep but since 4% higher toxicity so don’t bother except…….

Articaine – starts working a little faster and may be more profound.  No difference for block or max infiltration but is for infiltration in mand (v lido) Kung JOE 2015

I have an entire blog post on the articaine v lidocaine argument.

Dental local anesthetics and their health risks

Methemoglobinemia will show clinically as blue lips and shortness of breath. It can result from benzocaine, prilocaine, and to a lesser extent lidocaine and possibly articaine.

TCA (Tricyclic antidepressants) and epinephrine can cause high blood pressure and heart rhythm issues. This seems to be pretty low risk in dentistry. Below is a partial list of TCAs.

  • Amitriptyline or Elavil.
  • Amoxapine.
  • Desipramine (Norpramin)
  • Doxepin or Sinequan.
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
  • Protriptyline (Vivactil)
  • Trimipramine (Surmontil)

Non specific Beta blockers and epinephrine can cause a stroke, however, the doses we use are likely too low even if an inadvertent direct vein or artery injection occurs. Below is a list of non selective Beta blockers.

  • Propranolol.
  • Bucindolol (has additional α1-blocking activity)
  • Carteolol.
  • Carvedilol (has additional α1-blocking activity)
  • Labetalol (has additional α1-blocking activity) or Trandate
  • Nadolol or Corgard
  • Oxprenolol (has intrinsic sympathomimetic activity)
  • Penbutolol (has intrinsic sympathomimetic activity)
  • Pindolol or Visken

Alpha blockers and phenothiazines can cause epinephrine reversal with results in vasodilation and we see short action of local anesthetic and more bleeding. If on these then we switch to levonordefrin anesthetic. Very unlikely to be on an alpha blocker.

Dental anesthetic impact on alpha blocker

Dental anesthetic

Dental local anesthetics by weight

This is a list of the common dental local anesthetics used in dentistry and how much can be used on a patient by weight. Most dental local anesthetics are about 2mg/lb. However, bupivicaine is about .5mg/lb which is why despite it being only .5% the number of carpules max is about the same as the 2% anesthetics. That works out to 1 carp of 2% dental anesthetic for every 20lbs. The formula % x20=mg/carpule is also useful.

Graph of dental local anesthetics by weight

Dental anesthetic injection techniques

Dental anesthetic injection techniques vary from dentist to dentist. I will cover a few studies on techniques in this section. An interesting study I ran across in JOE was on the impact of IAN injection and patient positioning. I was unaware that having the patient remain in the supine position results in slightly better success rates of anesthesia.

Wand vs traditional method

No difference in pain or time of onset found in study however, this study is on maxillary molars in kids. Why even bother with the wand in maxilla?

Dental local anesthetic injection injuries

We have an entire post on dental anesthetic nerve damage.

Having mandibular nerve block failures?

When the IAN block is successful but still does not produce sufficient anesthesia for the patient try

  1. Switch dental local anesthetic type, which is good advice for any failures not just blocks.
  2. Lingual infiltration to anesthetize accessory innervation via the mylohyoid from the lingual
  3. Anesthetize retromolar area 8% have retromolar foramina that may be accessory innervation from long buccal
  4. In anterior cross the midline and place anesthetic
  5. Try switching to Gow-Gates (many feel this is superior from the get go).  Also would likely get any bifurcated mandibular nerves which are thought to occur .1-.9% (pretty low really) and innervation from long buccal through the retromolar foramina.
  6. PDL and Intraosseous

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