Os 2

Oral Surgery
(Local Anesthesia)
Lec.: 1 Dr. Saif Saadedeen
“Introduction to Local Anesthesia”

Many dental procedures, such as tooth extraction, are both painful and prolonged and
should be performed without pain by the using a local anesthesia.
Local anesthesia has been defined as “loss of sensation in a circumscribed area of the
body caused by inhibition of the conduction process in the peripheral nerves”.
An important feature of local anesthesia is that it produces this loss of sensation without
inducing loss of consciousness. In this one major area, local anesthesia differs
dramatically from general anesthesia.
Many methods are used to induce local anesthesia. However, only those methods or
substances that induce a transient and completely reversible state of anesthesia have
application in clinical practice.
Brief history:
Local anesthesia as it is known today began when a German chemist (Albert Niemann-
1860) successfully isolated the active principle of coca leaf, he named it cocaine. In 1898
professor Heinrich Braun introduced procaine as the first derivative of cocaine which is
known as the first synthetic local anesthetic drug. In 1940 the first modern local anesthetic
agent was introduced and known as Lidocaine (trade name Xylocaine). It relieves pain
during the dental surgeries and produces the desired anesthetic effect for several hours.
Terminology:
Pain: According to the World Health Organization (WHO) pain is defined as an
“unpleasant sensation that occurs from imminent tissue damage”. From a physiological
perspective, pain is a warning system. During dental treatment, patients will experience
pain as something unpleasant.
Analgesia: loss of pain.
Anesthesia: loss of sensation (loss of pain and touch sensation).

• In dentistry, local anesthesia is used to permit the performance of surgery or other
painful procedures with no pain.
Paresthesia: altered sensation (tingling), such as when a local anesthesia is starting to

work or its effect is wearing off. Or when a damaged nerve is regenerated.
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The effect of local anesthetics on nerve fiber has been shown to be dependent on:
1- The duration of exposure of local anesthesia
2- Concentration
3- Volume of the solution
Relative analgesia: is a sedation technique in which the patient remains conscious but
mental relaxation is induced by inhalation of a mixture of nitrous oxide and oxygen.
Properties deemed most desirable for a local anesthetic:

1. It should not be irritating to the tissue to which it is applied.
2. It should not cause any permanent alteration of nerve structure.
3. Its systemic toxicity should be low.
4. The time of onset of anesthesia should be as short as possible.
5. The duration of action must be long enough to permit completion of the procedure.
6. It should be relatively free from producing allergic reactions.
7. It should be stable in solution and should readily undergo biotransformation in the
body.
8. It should be sterile.
Of paramount importance is systemic toxicity, because all injectable and most topical
local anesthetics are eventually absorbed from their site of administration into the
cardiovascular system.
Several of the more potent injectable local anesthetics (e.g., procaine, mepivacaine)
prove to be relatively ineffective when applied topically to mucous membranes. To be
effective as topical anesthetics, these drugs must be applied in concentrations that prove
to be locally irritating to tissues while increasing the risk of systemic toxicity.
Lidocaine, on the other hand, is effective anesthetic when administered by injection or

topical application in clinically acceptable concentrations.
Clinical duration of action does vary considerably among drugs and also among different
preparations of the same drug, as well as by the type of injection administered (e.g., nerve
block vs. supraperiosteal). The duration of anesthesia necessary to complete a procedure
is a major consideration in the selection of a local anesthetic.
“Uses or indications of local anesthesia”

Local anesthesia is indicated in almost all the dental procedures, it is used to render the
teeth, the supporting tissues and associated structures insensitive to painful stimuli.
A. Diagnostic:
Administration of LA can be a useful way of finding the source of patient’s pain. An
example of this is the pain of pulpitis which can be very difficult for both the patient and the
dentist to isolate because of its tendency to be referred to other parts of the mouth or face,
so LA can differentiate between maxillary and mandibular sources, and even between
individual upper teeth provided they are not immediately adjacent.
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Another example is a patient with myofacial pain who is convinced that an upper tooth is
causing the problem, LA may help this patient and the surgeon in this situation to eliminate
the tooth as the cause of pain and may thus avoid unnecessary treatment.
B. Therapeutic:
LA can constitute part of a treatment for painful conditions, for example, the use of block
technique to eliminate the pain of dry socket. Blocks of the inferior alveolar nerve, mental
nerve or infraorbital nerve can also be used for the treatment of trigeminal neuralgia when
pain breakthrough.
C. Preoperative:
The provision of pain-free operation is by far the most common use of LA providing an
effective and safe method for almost all outpatient dentoalveolar surgical procedures. It
can in conjunction with sedation techniques allows more difficult procedures to be carried
out without the additional risks of general anesthesia and this is particularly of value in
patients with significant cardiovascular or airway diseases.
D. Adjunct to General Anesthesia:

LA is also given to patients undergoing oral and maxillofacial surgery under general
anesthesia this serves the following purposes:
1. It reduces the depth of general anesthesia needed.
2. It reduces the arrhythmia during surgery when significant stimulation is taking place,
for example when a tooth is being elevated.
3. It provides local homeostasis to the operative site.
4. Provides immediate postoperative analgesia.
E. Postoperative
After surgery with either local or general anesthesia the continuous effect of the
anesthesia is the most beneficial way of reducing patient’s discomfort, it helps to reduce or
even eliminate the need for a stronger systemic analgesic.
“Contraindications of local anesthesia”

These can be divided into two groups:
1- Absolute contraindications:
A. History of allergy to local anesthetic agent
Local anesthetic agents belong to the same chemical group should not be used.
However, LA agents in the different chemical group can be used. For example, if the
patient gives a history of allergy to an amide local anesthetic agent, an ester LA agent
should be used.
B. History of allergy to other constituents of the local anesthetic

solution
When the patient has a history of allergy to any of the constituents of the LA solution, it
should be avoided, a different type of solution should be used.
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2- Relative contraindications:
A. Uncooperative patient.
B. Presence of acute inflammation or suppurative infection at the site of injection, to avoid

the spread of infection (with the passages of the needle) from the abscess area to the
deeper tissue.
C. Patient with a significant medical disease such as cardiovascular disease, hepatic

dysfunction, renal dysfunction, clinical hyperthyroidism, etc.
D. Major surgical procedures (needs to be done under general anesthesia).
Advantages of local anesthesia

1. Less expensive than general anesthesia (GA).
2. No special preparation of the patient is needed as in GA.
3. No complicated apparatus is needed.
4. Less complication rate than GA.
5. The patient remains awake with no need for aftercare.
6. Can be used if GA is contraindicated (the patient is unfit for GA).
7. Anesthetist and other additional trained personnel are not required.
8. The technique is not difficult to master.
The end of the Lecture

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Oral Surgery

“Introduction to Local Anesthesia”

Analgesia: loss of pain.

Anesthesia: loss of sensation (loss of pain and touch sensation).

Paresthesia: altered sensation (tingling), such as when a local anesthesia is starting to

Properties deemed most desirable for a local anesthetic:

Lidocaine, on the other hand, is effective anesthetic when administered by injection or

“Uses or indications of local anesthesia”

D. Adjunct to General Anesthesia:

“Contraindications of local anesthesia”

B. History of allergy to other constituents of the local anesthetic

B. Presence of acute inflammation or suppurative infection at the site of injection, to avoid

C. Patient with a significant medical disease such as cardiovascular disease, hepatic

D. Major surgical procedures (needs to be done under general anesthesia).

Advantages of local anesthesia

The end of the Lecture

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