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Supplementary anesthesia Dr. Mohammed Amjed/ BDS, MSc, PhD/ 21.11.2023 Dr. Mohammed Amjed Alsaegh, UoS, 2023 1 Objectives: • Topical anaesthesia • Jet injection • Intrapapillary anaesthesia • Intraosseous anaesthesia • Intraligamentary anaesthesia • Intraseptal anaesthesia • Intrapulpal anaesth...

Supplementary anesthesia Dr. Mohammed Amjed/ BDS, MSc, PhD/ 21.11.2023 Dr. Mohammed Amjed Alsaegh, UoS, 2023 1 Objectives: • Topical anaesthesia • Jet injection • Intrapapillary anaesthesia • Intraosseous anaesthesia • Intraligamentary anaesthesia • Intraseptal anaesthesia • Intrapulpal anaesthesia • Transcutaneous electronic nerve stimulation Dr. Mohammed Amjed Alsaegh, UoS, 2023 2 Supplementary anesthesia Methods of anesthesia other than infiltration and regional block methods that are used in dentistry. This includes: • Topical anaesthesia • Jet injection • Intrapapillary anaesthesia • Intraosseous anaesthesia • Intraligamentary anaesthesia • Intraseptal anaesthesia • Intrapulpal anaesthesia • Transcutaneous electronic nerve stimulation Dr. Mohammed Amjed Alsaegh, UoS, 2023 3 Topical Anesthesia Topical anesthetics may achieve beneficial effects prior to needle penetration. Such effects may be psychological & pharmacological. what that influence the pharmacological efficacy of topical anesthetics GFactors include:7 effectiveness • The agent employed Itypeofanesthesia • Duration of application • Site of application consider the appropriate concentration of the anesthetic solution to achieve the desired level of anesthesia without causing adverse effects. Adjusting the concentration allows for control over the rate of absorption and the depth of anesthesia achieved. The transfer of the anesthetic through the mucosa is concentration dependent Dr. Mohammed Amjed Alsaegh, UoS, 2023 4 I Topical Anesthesia The agent Different delivery vehicles are used to administer topical anesthetics. These include: • aerosols • ointments • gels • pastes • powders! • solutions! Dr. Mohammed Amjed Alsaegh, UoS, 2023 5 Topical Anesthesia Site The effectiveness of topical anaesthesia varies in different parts of the mouth. 1. Mandibular buccal fold 2. Maxillary buccal fold 3. Palatal mucosa best Some reductions in the response of dental pulps to electrical stimulation have been reported following application of topical anaesthesia to the overlying mucosa !!! Application of the topical anesthetic gel: - Wipe the injection site with a clean gauze (antisepsis of the injection site is optional) - Before the injection, apply topical anesthesia for 2-5 minutes, wipes of excess Dr. Mohammed Amjed Alsaegh, UoS, 2023 it suggests that the nerves inside the teeth become less sensitive to electrical signals after using topical anesthesia on the nearby surface. This reduction in sensitivity is a desired outcome, as it helps in minimizing pain or discomfort during dental procedures. 6 jet injection topicalanesthesia Jet injection works by forcing anesthetic through mucosa under pressure Jet injection is based on the principle that Iliquids forcedKthrough very small openings, called jets, 11at very high pressure can penetrate intact skin or mucous membrane Some devices accept dental local anesthetic cartridges; with others the solution has to be drawn up into a reservoir in the injector. Dr. Mohammed Amjed Alsaegh, UoS, 2023 7 jet injection Indications: 1. The primary purpose of the jet injector is to obtain topical anesthesia before insertion of a needle. 2. it may be used to obtain mucosal anesthesia of the palate. Anesthetize palatalmucosa Advantages: Needle-free injection system Disadvantages 1. Occasionally hematoma formation at the site of use. 2. Spillage of anesthetic solution into the mouth tastes unpleasant. Dr. Mohammed Amjed Alsaegh, UoS, 2023 8 intrapapillary anaesthesia Gwhydowegofor 1. Localized anesthesia and hemorrhage control during periodontal surgery or operative dentistry. 2. Palatal anaesthesia following buccal infiltration. It is particularly useful in children AGILE.ae fffabuccalinfilterato Q.Whatsthetechniquefor intrapap The needle is inserted at the buccal aspect of the papilla; a site about 2 mm apical to the tip of the papilla the needle parallel to the occlusal plane and solution injected slowly. Blanching of the papilla indicates successful deposition. Dr. Mohammed Amjed Alsaegh, UoS, 2023 9 OIntraosseous Anaesthesia - Deposition of anesthetic solution directly into the cancellous space - Technique may be performed with conventional dental local anesthetic delivery systems. However, the introduction of specialized equipment has made this method easier to carry out. Dr. Mohammed Amjed Alsaegh, UoS, 2023 10 Intraosseous Anesthesia - The point of penetration is identified - It should lie in attached gingiva and is determined by imagining two lines perpendicular to one another. - The horizontal line passes along the buccal gingival margins of the teeth. The vertical line bisects the distal interdental papilla of the tooth that is being anesthetized. - The site of perforation is 2 mm apical to the intersection of these lines. - If this is located within reflected mucosa an area of attached gingiva coronal to this is chosen. (why?) Dr. Mohammed Amjed Alsaegh, UoS, 2023 11 Intraosseous Anaesthesia BeforePerforation - The area of perforation is infiltrated with 0.2 mL of local anesthetic. - The perforator is used one minute later when gingival anaesthesia has occurred. When using the specialized equipment, the perforator is advanced through the anaesthetized gingiva and bone using a slow speed hand piece - Following removal of the perforator, the short (6 mm) 27-gauge needle is inserted through the perforation into the cancellous space - About 1 mL of solution is delivered slowly (over a two-minute period) - 0.5 if single or 2 teeth, 1.8 if multiple teeth to be treated Dr. Mohammed Amjed Alsaegh, UoS, 2023 12 Dr. Mohammed Amjed Alsaegh, UoS, 2023 13 Intraosseous Anaesthesia Intraosseous Anaesthesia whenshould Q The technique should be avoided in cases of 1. Active periodontal disease 2. Little interradicular bone 3. Limited attached gingiva Duration and spread of anaesthesia The onset of intraosseous anaesthesia is rapid, ranging from 10 to 120 seconds. The success falls off rapidly over an hour and the decline in anesthesia seems to be more rapid with anterior teeth. Dr. Mohammed Amjed Alsaegh, UoS, 2023 14 Intraosseous Anaesthesia Advantages of intraosseous anaesthesia • a smaller dose is required • a smaller area of soft tissue anaesthesia is produced • The method aids in overcoming failure of conventional techniques Disadvantages of intraosseous anesthesia • Technically more difficult than infiltration anaesthesia • Specialized equipment may be required • Post-injection discomfort may be produced • Teeth may be damaged Dr. Mohammed Amjed Alsaegh, UoS, 2023 15 Intraosseous Anaesthesia Dr. Mohammed Amjed Alsaegh, UoS, 2023 16 Intraosseous Anaesthesia Originally, IO anesthesia necessitated the use of a half-round bur to provide entry into interseptal bone that had been surgically exposed. Once the hole had been made, a needle would be inserted into this hole and local anesthetic deposited. In recent years, the IO technique has been modified with the introduction of several devices that simplify the procedure. The Stabident System was introduced, followed later by the X-Tip, and most recently by the IntraFlow. - The Stabident System consists of two parts: a perforator—a burr that perforates the cortical plate of bone with a conventional slow-speed contra-angle handpiece—and an 8-mm long, 27gauge needle that is inserted into this predrilled hole for anesthetic administration Dr. Mohammed Amjed Alsaegh, UoS, 2023 17 Intraosseous Anaesthesia - X-Tip system Dr. Mohammed Amjed Alsaegh, UoS, 2023 18 Intraosseous Anaesthesia Dr. Mohammed Amjed Alsaegh, UoS, 2023 19 Dr. Mohammed Amjed Alsaegh, UoS, 2023 20 Intraosseous Anaesthesia The IntraFlow HTP Anesthesia Delivery System, which was recently introduced, combines the two steps of x-tip into one Dr. Mohammed Amjed Alsaegh, UoS, 2023 21 Intraligamentary (Periodontal Ligament) Anesthesia - Solution injected via the periodontal ligament reaches the pulpal nerve supply by entering the cancellous bone via perforations in the socket wall, not by travelling down the length of the ligament - Potential benefit of the PDL injection lies in the fact that it provides pulpal and soft tissue anesthesia in a localized area - The duration of intraligamentary anaesthesia between individuals is marked. The duration of reliable pulpal anaesthesia is around 15 minutes for single-rooted teeth and rather less for molars. Dr. Mohammed Amjed Alsaegh, UoS, 2023 22 Intraligamentary (Periodontal Ligament) Anaesthesia Dr. Mohammed Amjed Alsaegh, UoS, 2023 23 Intraligamentary (Periodontal Ligament) Anesthesia Technique - It is recommended that the site of penetration is swabbed with an antiseptic solution. - Although the injection can be performed using either conventional or specialized syringes, it is easier with an intraligamentary syringe. Complains and Justifications? - A 30-gauge needle is recommended. The needle is inserted at the mesiobuccal aspect of the root(s) at 30 degrees to the long axis of the tooth. The needle is advanced to maximum penetration until it is wedged between the tooth and the alveolar crest. Progression deep into the periodontal ligament is not usually possible. l - Bevel direction is not important: If the bevel of the needle faces the alveolar wall this reduces the chances of blockage. - The orientation of the needle, however, is unrelated to the success of the technique. What happens if the bevel toward the tooth? The bevel of the needle face toward the root to permit easy countered advancement of the needle in an apical direction. whdnyi.sndfnisen - Once the needle is correctly positioned, the solution is injected under backpressure. It is recommended that 0.2 mL of solution is deposited into the periodontium of each root. - When using the specialized syringes, the needle should remain in position for about 10 seconds following depression of the lever to allow escape of solution from the cartridge. O O Dr. Mohammed Amjed Alsaegh, UoS, 2023 24 Intraligamentary (Periodontal Ligament) Anaesthesia There are two important indicators of success of the injection: (1) Significant resistance to the deposition of local anesthetic solution (2) Ischemia of the soft tissues adjacent to the injection site. (This is noted with all local anesthetic solutions but is more prominent with vasoconstrictor-containing local anesthetics.) - If the tooth is multirooted, remove the needle and repeat the procedure on the other root(s). Dr. Mohammed Amjed Alsaegh, UoS, 2023 25 Intraligamentary (Periodontal Ligament) Anaesthesia Advantages of intraligamentary anaesthesia • smaller dose required • rapid onset of anaesthesia • the method aids in overcoming failure of conventional techniques bleeduncontrollably • only a small area of soft tissue is anaesthetized peoplewho • it is useful in the mandible for patients with bleeding diatheses. (avoid reginal block) • Its use as a possible aid in the diagnosis (e.g., localization) of mandibular pain Disadvantages of intraligamentary anaesthesia • the production of a bacteraemia • peri- and postinjection discomfort can occur • damage to dental and periodontal tissues can be caused • damage to equipment may be produced. by numbing a speci c tooth or area, it can help dentists identify if that tooth is causing the pain. If the pain lessens after the injection, it suggests that the treated tooth is likely the source of the pain. Contraindications to the PDL injection: Infection or severe inflammation at the injection site and for primary teeth ? Dr. Mohammed Amjed Alsaegh, UoS, 2023 26 Dr. Mohammed Amjed Alsaegh, UoS, 2023 27 Intraseptal Anaesthesia a hybrid of intraligamentary and intraosseous anesthesia. More effective in younger patients Effect is identical to intraligamentary injection A short 27-gauge needle is inserted into the buccal interdental papilla, injecting while it is directed toward the bone - The technique may be used instead of the intraligamentary method if the periodontal condition is poor. - While applying pressure to the syringe, push the needle slightly deeper (1 to 2 mm) into the interdental septum. - Deposit 0.4 mL of local anesthetic in not less than 20 seconds. Dr. Mohammed Amjed Alsaegh, UoS, 2023 28 Intraseptal Anaesthesia Area of insertion & Target area: both are the center of the interdental papilla adjacent to the tooth to be treated Bevel facing the apex of the tooth Dr. Mohammed Amjed Alsaegh, UoS, 2023 29 Dr. Mohammed Amjed Alsaegh, UoS, 2023 30 Intrapulpal Anaesthesia intopulpcanal depositLAdirectly The intrapulpal injection provides pain control through both the pharmacologic action of the local anesthetic and applied pressure. This technique may be used once the pulp chamber is exposed surgically or pathologically. Indication When pain control is necessary for pulpal extirpation or other endodontic treatment in the absence of adequate anesthesia from other techniques. Ideally, wedge the needle firmly into the pulp chamber or root canal. Instrumentation may begin approximately 30 seconds after the injection is given Dr. Mohammed Amjed Alsaegh, UoS, 2023 32 Intrapulpal Anaesthesia Technique - This method of anaesthesia relies on deposition of solution directly into the pulp canals. - Usually it will be administered following the injection of an anesthetic solution by another route. - It is essential that the solution is injected into the pulp under pressure. - Fit is tight either by opening by small round bur into the chamber or if not can done by inserting the needle deep in the canal. - Around 0.2 mL of solution is injected. Dr. Mohammed Amjed Alsaegh, UoS, 2023 31 Intrapulpal Anaesthesia Advantages of intrapulpal anaesthesia • success is independent of the solution • the method aids in overcoming failed conventional methods • single tooth anaesthesia may be obtained • there are minimal systemic effects. Disadvantages of intrapulpal anaesthesia • discomfort may be produced • application of the method is limited. Dr. Mohammed Amjed Alsaegh, UoS, 2023 33 Transcutaneous Electronic Nerve Stimulation - Non-pharmacological methods of anesthesia - Both reducing the discomfort of injections and as a method of achieving pulpal anesthesia. - TENS has been shown to decrease the discomfort of infiltration and inferior alveolar nerve block injections. This method of anesthesia can provide pain control for operative dentistry in some patients. However, success is poor for endodontic - The technique involves the use of electrical leads applied either to the region of injection or close to the nerve supplying the tooth in question. - - This application can be either intra- or extraoral and the leads may be attached to the operator’s finger or the patient’s mucosa or skin. The frequency and amplitude of the stimulation from the electrodes is controlled by a console. The frequency is normally preset but the patient controls the amplitude. The patient adjusts the strength of the signal until a pleasant vibratory sensation is experienced. As accommodation occurs, the patient gradually increases the amplitude of the current. Dr. Mohammed Amjed Alsaegh, UoS, 2023 34 The end Dr. Mohammed Amjed Alsaegh, UoS, 2023 35