Management of Local Anaesthesia in Endodontics

1. Management of Local Anaesthesia in Endodontics By Dr. Muna Q. Marashdeh

2. Factors Affecting Endodontic Anesthesia • Apprehension and Anxiety • Fatigue • Tissue inflammation (hyperalgesia) • Previous unsuccessful anesthesia ( psychologic management, supplemental techniques)

3. Conventional Anesthesia • Mndibular Anesthesia • Maxillary Anesthesia

4. Supplemental Anesthesia • Periodontal Ligament Injection • Intraosseous Anesthesia • Intrapulpal Injection

5. Conventional Anesthesia Success of local anesthesia is variable, a number of factors affect the anesthesia, such as • The type of the procedure • Arch location • Anxiety level • Presence of inflammation

6. Conventional Anesthesia • Mndibular Anesthesia Anesthetic agent ( 2% lidocaine with 1:100,000 epinephrine )Related FactorsLip numbness (5-7 min)Onset of pulpal anesthesia ( 10-15 min)Duration ( 2 ½ hrs)Success ( M, PM > Inc)

7. Conventional Anesthesia • Mndibular Anesthesia Alternative techniquesIncreasing the volume Alternative injection locationsInfiltration injectionsLong- acting anesthesiaAccessory innervationCross innervationPain and inflammation

8. Conventional Anesthesia • Maxillary AnesthesiaRelated factorsLip numbness (quick)Success and failure ( infiltration> ID block)Onset of pulpal anesthesia (3-5 min)Duration ( 30-60 min)

9. Conventional Anesthesia • Maxillary Anesthesia Alternative techniquesVolume of solutionAlternative solutionOther techniquesPain and inflammation

10. Supplemental Anesthesia • Indications The supplemental injection used if the standard technique is not effective It is useful to repeat the conventional technique only if the patient is not exhibiting the classic signs of soft tissue numbness

11. Supplemental Anesthesia • Periodontal Ligament Injection Useful if conventional is unsuccessful Particularly if rubber dam is in place Standard syringe or pressure syringe 30,27,25 gauge short needle The needle is inserted into the mesial gingival sulcus at a 30 degree angle

12. Periodontal Ligament Injection The needle is supported, positioned with maximum penetration( wedged between root and crestal bone) Heavy pressure is slowly applied for 10-20 sec Back pressure is important The injection is then repeated on the distal surface (0.2 ml on each side)

13. Periodontal Ligament Injection Mechanism of action: the PDL injection forces anesthetic solution through the cribriform plate into the marrow spaces and into the vasculature in and around the tooth. The primary route is not the periodontal ligament, the mechanism of action is not related to direct pressure on the nerve

14. Periodontal Ligament Injection Onset of anesthesia (rapid, no waiting) Success ( primary injection good, as supplemental good) Duration 10-20 min Postoperative discomfort ( mild from 14 hr-3days)

15. Pressure Syringe Pressure syringe has the same effect of the standard syringe

17. Supplemental Anesthesia • Intraosseous AnesthesiaThe IO injection allows placement of local anesthetic directly into the cancellous bone adjacent to the tooth

18. Intraosseous Anesthesia • Two components system,\ • slow speed handpiece - driven perforator • matching 27-gauge ultrashort injector needle

19. Intraosseous Anesthesia • Technique The area of perforation and injection is on a horizontal line of the buccal gingival margins of the adjacent teeth and a vertical line that passes through the interdental papilla distal to the tooth to be injected. A point approximately 2mm below the intersection of these lines is selected as the perforation site. Slow injection over a period of 1-2 min

23. Intraosseous Anesthesia • Perforator breakage (rarely) • Selection of perforator site ( distal except 2nd molar mesial) • Onset of anesthesia ( no waiting period) • Success ( primary injection good, supplemental injection excellent )

24. Intraosseous Anesthesia • Failure (if the anesthetic solution squirts out of the perforation, redo the perforation) • Duration ( primary injection less than 1 hr, supplemental very good duration) • Postoperative problems ( no or mild pain)

25. Supplemental Anesthesia • Intrapulpal Injection • Indications On occasion the IO and PDL injections do not produce profound anesthesia IP injection shouldn’t be used without trying other supplemental method, it is very painful

26. Intrapulpal Injection The patient must be informed that there will be a sharp sensation Strong back-pressure has been shown to be the major factor in producing anesthesia Duration of pulpal anesthesia ( 15-20 min)

27. Intrapulpal Injection Either to inject each canal after the chamber is unroofed, or give the pulp chamber after stoppering the access with cotton pellet, wax, rubber….. A standard syringe with a bent short needle is used. Fingers support the needle shaft to prevent buckling

28. Intrapulpal Injection The needle is positioned in the access opening and then moved down the canal, while slowly expressing the anesthetic to the point of wedging Maximum pressure is applied slowly in to the syringe for 5-10 sec. If there no back- pressure go deeper, change gauge

29. Intrapulpal Injection

30. Thank you