com TABLE 4-4 TABLE 4-17 Maximum Recommended Dosages (MRDs) of Local Duration of Pulpal and Soft Tissue Anesthesia for Anesthetics Available in North America Available Local Anesthetics MANUFACTURER’S AND FDA (MRD) DURATION (APPROXIMATE MINUTES) Local Anesthetic mg/kg mg/lb MRD, mg Drug Formulation Pulpal Soft Tissue Articaine With vasoconstrictor 7.2 None listed Mepivacaine 3% (infiltration) 5-10 90-120 Bupivacaine Prilocaine 4% (infiltration) 10-15 60-120 With vasoconstrictor None listed None listed 90 Prilocaine 4% (nerve block) 40-60 120-240 With vasoconstrictor 2.9 90 Articaine 4% + epinephrine 45-60 180-240 (Canada) 1 : 200,000 Lidocaine Lidocaine 2% + epinephrine 60 180-300 With vasoconstrictor 7.2 500 1 : 50,000 Mepivacaine Lidocaine 2% + epinephrine 60 180-300 No vasoconstrictor 6.0 400 Mepivacaine 2% + 60 180-300 Prilocaine levonordefrin 1 : 20,000 No vasoconstrictor 8.6 600 Articaine 4% + epinephrine 60-75 180-300 With vasoconstrictor 8.6 600 1 : 100,000 Prilocaine 4% + epinephrine 60-90 180-480 CALCULATION OF MILLIGRAMS OF 1 : 200,000 LOCAL ANESTHETIC PER DENTAL Bupivacaine 0.8 mL CARTRIDGE) epinephrine 1 : 200,000 Local Percent × 1.8 mL = Anesthetic Concentration mg/mL mg/Cartridge Articaine 4 40 72* Bupivacaine 0.5 5 9 Lidocaine 2 20 36 Mepivacaine 2 20 36 3 30 54 Prilocaine 4 40 72 MRD, Maximum recommended dose. *Cartridges of some drugs in the United States read, “1.” The actual volume of all local anesthetic cartridges is approximately 1.com This page intentionally left blank www. Malamed, DDS Professor of Anesthesia and Medicine School of Dentistry University of Southern California Los Angeles, California with 441 illustrations www.com To Beverly, Heather, Jennifer, and Jeremy, and the next generation: Matthew, Rachel, Gabriella, Ashley, Rebecca, Elijah, and Ethan www.com This page intentionally left blank www.com Contributors Daniel L. Orr II, BS, DDS, MS (Anesthesiology), Mark N.
Hochman, DDS PhD, JD, MD Private Practice Limited to Periodontics Professor and Director Orthodontics and Implant Dentistry Oral and Maxillofacial Surgery and Advanced Pain Control Specialized Dentistry of New York University of Nevada Las Vegas School of Dental Medicine New York City, New York Las Vegas, Nevada Clinical Associate Professor Clinical Professor New York University Oral and Maxillofacial Surgery College of Dentistry University of Nevada School of Medicine New York City, New York Las Vegas, Nevada Clinical Consultant Milestone Scientific, Inc. Livingston, New Jersey vii www.com This page intentionally left blank www.com Preface The sixth edition of Handbook of Local Anesthesia! switch) to increase patient comfort during injection, decrease As happened with previous editions, I truly find it hard to onset time of anesthesia, and, perhaps, increase the depth comprehend how many years have transpired since the 1st of anesthesia; phentolamine mesylate (the local anesthetic edition was published in 1978. It has been 8 years since the “OFF” switch) giving the doctor the opportunity to signifi fifth edition and in this time there have been a significant cantly minimize the duration of a patients residual soft tissue number of changes, many of them advances, in the art and anesthesia, thereby minimizing the risk of self-inflicted soft science of pain control in dentistry. Though the drugs remain the same—articaine HCl, bupi I have asked Dr.
Mark Hochman to rewrite the discussions vacaine HCl, lidocaine HCl, mepivacaine HCl, and prilocaine in this edition on C-CLAD devices (Chapter 5—The Syringe) HCl—the years since the fifth edition have seen the introduc and the local anesthetic techniques associated with it (Chapter tion and refinement of drugs and devices which work to help 15—Supplemental Injections and Chapter 20—Future Con the dental profession come ever closer to the twin goals of siderations). Hochman has been intimately involved with truly pain free dentistry and truly pain free local anesthetic the development of C-CLAD since the mid-1990s and is injections. the author of a number of refereed papers on the subject As I have stated repeatedly in previous editions, “Local including two injection techniques—AMSA (anterior middle anesthetics are the safest and the most effective drugs avail superior alveolar nerve block) and P-ASA (palatal—anterior able in all of medicine for the prevention and the management superior alvelar nerve block) that were developed as a result of pain. Indeed, there are no other drugs that truly prevent of his research into computer delivery of local anesthetics.
pain; no other drugs which actually prevent a propagated A DVD accompanied the fifth edition of Local Anesthesia. nociceptive nerve impulse from reaching the patient’s brain, It followed the structure of the textbook, providing clinical where it would be interpreted as pain. Deposit a local anes demonstrations of the techniques and concepts presented in thetic drug in close proximity to a sensory nerve and clinically the text. The DVD has proven to be a highly effective teaching adequate pain control will result in essentially all clinical device and is used, both legally and (sadly) illegally, by stu situations.” dents, dentists and dental hygienists throughout the world.
Find the nerve with a local anesthetic drug and pain control A supplemental disk has been incuded with the original is virtually assured. Yet in certain clinical situations “finding 2-disk set which accompanies this sixth edition. The disk pres the nerve” remains a vexing problem. This is especially so in ents clinical updates on a number of the newer additions to the mandible, primarily permanent mandibular molars.
Over the local anesthetic armamentarium. It is my feeling, as an my 39 years as a teacher of anesthesia in dentistry I and my educator that the combination of the written text plus the dentist anesthesiologist colleagues have worked at “fixing” this visual impact of the DVD provides a more optimal learning problem. experience for all who come to study this critically important Have we succeeded? Not yet. Are we getting close to a solution? Yes.
Feedback from readers of this textbook is always appreci This sixth edition of Local Anesthesia includes new and/or ated. Should errors be noted, or suggestions for improvement expanded discussions of the periodontal ligament (PDL) be made, contact me at malamed@usc. injection—including the use of computer-controlled local anesthetic delivery (C-CLAD) systems for PDL (and other Stanley F. Malamed injections); the administration of the local anesthetic articaine HCl by mandibular infiltration in the adult mandible; buffer October 2011 ing of local anesthetic solutions (the local anesthetic “ON” Los Angeles, California, USA ix www.com This page intentionally left blank www.com Acknowledgments The people involved with the video production of the new supplemental DVD cannot receive enough thanks: Dr.
Joseph Massad and his excellent team at Millennium Productions. Thanks, too, to the manufacturers of local anesthetic drugs and devices in North America, including Beutlich Pharmaceuticals; Dentsply; Kodak (Cook-Waite); Midwest; Milestone Scientific; Novocol; Septodont, Inc; and Sultan Safety, LLC, for their assistance in supplying photographs and graphics for use in this edition. I also want to thank Brian S. Loehr, Senior Content Development Specialist; Rachel E.
McMullen, Senior Project Manager; and John J. Dolan, Executive Content Strategist, from Mosby (an affiliate of Elsevier) who had the unenviable task of dealing with a frequently lazy, usually hard-to-reach author. Their perseverance—once again—has paid off with this sixth edition. Finally, I wish to thank the many members of our profession, the dentists and dental hygienists, who have provided me with written and verbal input regarding prior editions of this textbook.
Many of their suggestions for additions, deletions, and corrections have been incorporated into this new text. Thanks to you all! Stanley F. Malamed December 2011 Los Angeles, California xi www.com This page intentionally left blank www.com Contents PART I THE DRUGS 1 Neurophysiology, 2 2 Pharmacology of Local Anesthetics, 25 3 Pharmacology of Vasoconstrictors, 39 4 Clinical Action of Specific Agents, 52 PART II THE ARMAMENTARIUM 5 The Syringe, 78 Mark N. Hochman 6 The Needle, 92 7 The Cartridge, 101 8 Additional Armamentarium, 110 9 Preparation of the Armamentarium, 113 PART III TECHNIQUES OF REGIONAL ANESTHESIA IN DENTISTRY 10 Physical and Psychological Evaluation, 124 11 Basic Injection Technique, 157 12 Anatomic Considerations, 169 13 Techniques of Maxillary Anesthesia, 188 14 Techniques of Mandibular Anesthesia, 225 15 Supplemental Injection Techniques, 253 Mark N.
Hochman 16 Anesthetic Considerations in Dental Specialties, 277 PART IV COMPLICATIONS, LEGAL CONSIDERATIONS, QUESTIONS, AND FUTURE 17 Local Complications, 292 18 Systemic Complications, 311 19 Legal Considerations, 341 Daniel L. 20 Future Trends in Pain Control, 356 Mark N. Hochman 21 Questions, 380 xiii www.com New to this Edition DVD SUPPLEMENT NEW INFORMATION A supplemental disk has been added to the original 2-disk set. Updated discussions of the armamentarium needed to The new DVD supplement presents clinical updates on a succeed in local anesthesia delivery number of the newer additions to the local anesthetic 119 of the Armam entarium armamentarium, including the local anesthesia “ON” and CHAPTER 9 Preparation “OFF” switches, and Computer-Controlled Local Anesthetic Delivery (C-CLAD).
(Courtesy the needle cap and discard. Remove e into the safety Septodont, Inc.) local anesthetic cartridg Figure 9-13. Insert the nt, Inc. (Courtesy Septodo Ar Artic ticain aine A barrel of the e the handle tip into the Figure 9-14.
Introduc Septodont, Inc., Bu Bupiv pivaca acaine ine injectable system, behind Lancaster, PA. B, Active aspiratio Figure 9-17.) tesy Septodont, Inc., Lancaste Lid Lidococain aine stopped), when released (injection a depression occurs, and and away from the protuberance the diaphragm moves back A). Me Mepivpivaca acaine ine aspiration occurs (Fig. Active aspiration is obtained by the sili- when, handle creating a vacuum cone top of the plunger B).
The oner pulls back (Fig. 9-17, thumb in ring, the practiti ng active aspiration, providi Pri Priloc locain aine Figure 9-15. While protectin ward toward the handle g the needle, slide the sheath until it CLICKS. (Courte back- sy Septodont, Inc., bung follows the which is best observe plunger d when of solution (providing space) tip, a minimu m of 0.35 mL has been expelled or used from Lancaster, PA.
When using only one n procedures using one Note: During multipl e injectio and locks the unit togethe r) may safely retain the syringe the sheath hits the handle cartridge, the practitioner the sheath toward the needle (Fig. for further use by moving are away from the needle. Remove position (Fig. All movements now until it reaches the holding 7.
The system is now ready to a second cartridge, follow from step the needle cap and discard you need to insert use (Fig. te the procedu re, slide the protective sheath To comple is the second notch at , which Aspiration toward the locking position now spiration). At the base of the car- 9-19, A and B). This has Passive Aspiration (Self-A is a the end of the barrel (Fig.
le system, you will see there in the protective sheath. tridge barrel of the injectab the locked the needle safely have as a blob of glue holding handle after use. After you small protuberance. Remove the plunger needle- end that penetra tes the dia- the injectab le system in the (B) position, hold centered needle, the.
At the start of the locked le system with one hand, and, e when inserted the barrel of the injectab phragm of the cartridg against the protuberance; gm is pressed injection, the diaphra 12/16/2011 14:37:41 Injectable Local Anesthetics are VASODILATORS Computer-controlled local anesthetic delivery (C-CLAD) systems Blood flow through area is INCREASED LA diffuses OUT of AREA more rapidly 84 PART II The Armamen tarium Figure 5-14. Foot-activ ated control of The Wand. Computer -controlled local anesthetic system—The Wand. delivery the movement of a penetrati ng needle.
The operator’ ity to precisely control s inabil- both of these activities injection can comprom during an ise an injection technique tion, a traditional syringe. In addi- is handled with a palm-thu grasp, which is not designed mb for ideal ergonomics or control during the injection needle. For certain practition those with small hands—j ers— ust holding a syringe with cartridge of anesthetic may a full be difficult. In 1997 the first computer -controlled local anestheti Figure 5-15.
The Wand delivery (C-CLAD) system c has a The Wand (Milestone was introduced into dentistry.