Local Anesthetics in Dentistry

Bach Van Pham

Southern Methodist University
November 30, 2004
 What are local anesthetics?
 Local anesthetic: produce loss of
sensation to pain in a specific area of the
body without the loss of consciousness
 History
 Coca leaves from the genus Erythroxylum
 Erythroxylum contains high concentration of alkaloid up
to 0.7-1.8%
 Alkaloid has natural nitrogen bases found in the coca
leaves, also known as cocaine
 Genus Erythroxylum discovered in South America,
Venezuela, Bolivia, and Peru since pre-Columbian
periods
 Earliest cultivation and use of the coca leaf went back to
about 700 BC in Bolivia and Andes regions
 New discoveries showed humans used coca more than
5,000 years ago in Ecuador
 History (cont.)
 Spanish conquistadors and explorers witnessed the
consumption of coca in South America
 Spaniards, such as Alfred Buhler, hypothesized a tribe in
the Negro River area called Arhuaco was the original
discoverers of the properties and functions of the drugs.
 In 1571, Pedro Pizarro, a conquistador of Inca, observed
nobles and high rank officials of the Inca empire
consumed the coca plant.
 After the fall of the Inca empire, coca consumption
spread widely to the population
 Development of general and local
anesthesia
 Took place in Western Europe from 1750 to 1850
 Chemists and physicians collected sample of coca leaves
for experiments
 Isolated active principle of coca leaf, synthesized to a
drug for patients to feel more relief of pain when taking
surgeries
 In 1860, German chemist Albert Niemann successfully
isolate the active principle of coca leaf; he named it
cocaine
 Development of general and local anesthesia
(cont.)
 In 1865, Willhelm Lossen determine the correct molecular formula
of cocaine (C17H21NO4)
 Niemann discovered the effect of numbness of the tongues caused
by alkaloid in 1860
 Based on Niemann’s discovery, Russian physician Basil Von Anrep
did experiments on animals, such as rats, dogs, and cats.
 He injected small quantity of 1% solution to his tongue; tongue
became insensitive
 He concluded cocaine is a good drug for surgical anesthetic
 William Steward Halsted and Richard John Hall developed the
inferior dental nerve block techniques for dentistry
 Cocaine Addiction

 More physicians began to do research of cocaine in the

clinic trials.
 The physician Sigmund Freud used the stimulant effect
of cocaine to treat the morphine addiction in patients
 An ophthalmologist Carl Koller realized the importance of
the alkaloid’s anesthetic effect on mucous membranes
 In 1884, he used the first local anesthetic on a patient
with glaucoma
 Freud, Halsted, and Koller became addicted to the drug
through self-experimentation
 Side Effects of Cocaine and Solutions
Solutions:
Minor:
 Used nitrous oxide gases and
 Addiction
ether for minor surgery in
 Intoxication
dentistry
 Give a low concentration of

Severe: cocaine; it slows down the

 Death release of the drug into the
bloodstream causing little side
effects
 Procaine replaced Novocaine
cocaine Problems
Took too long to set (i.e. to produce
the desired anesthetic result)
 In 1898, Professor Heinrich
Braun introduced procaine as
 Wore off too quickly, not nearly as
potent as cocaine
the first derivative of cocaine,
also known as the first
 Classified as an ester; esters have
high potential to cause allergic
synthetic local anesthetic drug
reactions
 Trade name is Novocaine®  Caused high conc. of adrenaline
resulted in increasing heart rate,
make people feel nervous
Most dentists preferred not to used any
local anesthetic at all that time; they
used nitrous oxide gas.
Today, procaine is not even available for
dental procedures.
 Lidocaine

 In 1940, the first modern local

anesthetic agent was lidocaine, trade
name Xylocaine®
 It developed as a derivative of xylidine
 Lidocaine relieves pain during the
dental surgeries
 Belongs to the amide class, cause little
allergenic reaction; it’s hypoallergenic
 Sets on quickly and produces a desired
anesthesia effect for several hours
 It’s accepted broadly as the local
anesthetic in United States today
 Differences of Esters and Amides

 All local anesthetics are weak bases. Chemical structure of local anesthetics
have an amine group on one end connect to an aromatic ring on the other
and an amine group on the right side. The amine end is hydrophilic
(soluble in water), and the aromatic end is lipophilic (soluble in lipids)
 Two classes of local anesthetics are amino amides and amino esters.
Amides: Esters:
--Amide link b/t intermediate --Ester link b/t intermediate chain and
chain and aromatic ring aromatic ring
--Metabolized in liver and very --Metabolized in plasma through soluble in
the solution pseudocholinesterases and not
stable in the solution
--Cause allergic reactions
 Structures of Amides and Esters
 The amine end is hydrophilic (soluble in water), anesthetic molecule
dissolve in water in which it is delivered from the dentist’s syringe into the
patient’s tissue. It’s also responsible for the solution to remain on either
side of the nerve membrane.
 The aromatic end is lipophilic (soluble in lipids). Because nerve cell is made
of lipid bilayer it is possible for anesthetic molecule to penetrate through the
nerve membrane.
 The trick the anesthetic molecule must play is getting from one side of the
membrane to the other.
 Mechanism
 The mechanism of local anesthetics connects with the ion channels,
nerve, and depolarization.
 Local anesthetics block the conduction in peripheral nerves that inhibited
the nerve to excited and created anesthesia.
 The anesthetic is a reversible reaction. It binds and activates the sodium
channels.
 The sodium influx through these channels and depolarizes the nerve cell
membranes. It also created high impulses along the way.
 As a result, the nerve loses depolarization and the capacity to create the
impulse, the patient loses sensation in the area supplied by the nerve.
 Factors Affect the Reaction of Local Anesthetics
Lipid solubility
 All local anesthetics have weak bases. Increasing the lipid solubility
leads to faster nerve penetration, block sodium channels, and speed
up the onset of action.
 The more tightly local anesthetics bind to the protein, the longer the
duration of onset action.
 Local anesthetics have two forms, ionized and nonionized. The
nonionized form can cross the nerve membranes and block the
sodium channels.
 So, the more nonionized presented, the faster the onset action.

pH influence
 Usually at range 7.6 – 8.9

 Decrease in pH shifts equilibrium toward the ionized form, delaying

the onset action.
 Lower pH, solution more acidic, gives slower onset of action
 Factors Affect the Reaction of Local Anesthetics
(cont.)
Vasodilation
 Vasoconstrictor is a substance used to keep the anesthetic solution in

place at a longer period and prolongs the action of the drug

 vasoconstrictor delays the absorption which slows down the

absorption into the bloodstream

 Lower vasodilator activity of a local anesthetic leads to a slower

absorption and longer duration of action

 Vasoconstrictor used the naturally hormone called epinephrine

(adrenaline). Epinephrine decreases vasodilator.

Side effects of epinephrine

 Epinephrine circulates the heart, causes the heart beat stronger and

faster, and makes people feel nervous.

 Toxicity
 Toxicity is the peak circulation levels of local anesthetics
 Levels of local anesthetic concentration administered to patients are
varied according to age, weight, and health.
 Maximum dose for an individual is usually between 70mg to 500mg

 The amount of dose also varied based on the type of solution used
and the presence of vasoconstrictor
Example:
---For adult whose weight is 150lbs and up, maximum dose Articaine
and lidocaine is about 500mg
---For children, the dosage reduced to about 1/3 to ½ depending on
their weight.
The doses are not considered lethal.
Some common toxic effects:
--light headedness ---shivering or twitching --seizures
--hypotension (low blood pressure) --numbness
 Factors of circulation levels
 Factors of circulation levels are the rates of absorption,
distribution, and metabolism.
 Absorption depends on the speed of administration and
levels of the doses.
 Distribution allows absorption to occur in three phases.
First, the drug occurs at highly vascular tissues in the
lungs and kidneys. Then it appears less in vascular
muscle and fat. Then the drug is metabolized.
 Metabolism involves in the chemical structure based on
two classes, amide and ester as discussed earlier.
 Decreasing the potential toxicity resulted in rapid
metabolism.
 Three special drugs used in dental anesthesia
 Bupivicaine (Marcaine®
--Produce very long acting anesthetic effect to delay the post operative pain from the
surgery for as long as possible
--0.5% solution with vasoconstrictor
--toxicity showed by the pKa is very basic
--Onset time is longer than other drugs b/c most of the radicals (about 80%) bind to
sodium channel proteins effectively
--most toxic local anesthetic drug

 Prilocaine (Citanest®)
--Identical pKa and same conc. with lidocaine
--Almost same duration as lidocaine
--Less toxic in higher doses than lidocaine b/c small vasodilatory activity


Articaine (Septocaine®)
--newest local anesthetic drug approved by FDA in 2000
--Same pKa and toxicity as lidocaine, but its half life is less than about ¼ of lidocaine
--Used with vasoconstrictor.
--Enters blood barrier smoothly
--The drug is widely used in most nations today
 Conclusion
Anesthetic pKa Onset Duration Max Dose
(with (with
Epinephrine) Epinephrine)
in minutes
Procaine 9.1 Slow 45 - 90 8mg/kg –
10mg/kg
Lidocaine 7.9 Rapid 120 - 240 4.5mg/kg –
7mg/kg

Bupivacaine 8.1 Slow 4 hours – 8 2.5mg/kg –

hours 3mg/kg
Prilocaine 7.9 Medium 90 - 360 5mg/kg –
7.5mg/kg
Articaine 7.8 Rapid 140 - 270 4.0mg/kg –
7mg/kg
 References
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Evolution of Local Anesthesia Since the Coca Leaf. © 2003 American
Society of Anesthesiologists Volume 98(6)   June 2003   pp 1503-1508.
 Peter C. Meltzer, Shanghao Liu, Heather S. Blanchette, Paul Blundell,
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Sparing Cocaine Antagonist. @ Bioorganic & Medicinal Chemistry Volume
10, Issue 11 , November 2002, Pages 3583-3591
 Shigeki Isomura, Timothy Z. Hoffman, Peter Wirsching, and Kim D. Janda.
Synthesis, Properties, and Reactivity of Cocaine Benzoylthio Ester
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 Mazoit, Jean-Xavier; Dalens, Bernard J. Pharmacokinetics of local
anesthetics in infants and children. Clinical Pharmacokinetics (2004),
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 Alejandro A. Nava-Ocampo and Angelica M. Bello-Ramirez. Lipophilicity

Affects the Pharmacokinetics and Toxicity of Local Anaesthetic Agents
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 Don R Revis, Jr. Local Anesthetics. October 14,2004: (Medline)
http://www.emedicine.com/ent/topic20.htm