Modern anesthetic drugs in outpatient dentistry

31/10/2021

Many people associate going to the dentist with something unpleasant, painful and terrible. Therefore, people often postpone treatment until the moment when the tooth hurts so much that the pain becomes impossible to bear. Indeed, in Soviet times, anesthesia was a “weak link”, and many manipulations were carried out without pain relief at all. But over the past 15 years, dentistry has come a long way. And now treating various diseases of the oral cavity is not painful at all. Modern anesthesia eliminates not only physical pain, but also reduces the patient’s psycho-emotional stress, which significantly increases the effectiveness and quality of treatment. All dental procedures are absolutely painless, be it caries treatment or implant installation.

Indications

Most dental procedures are performed under local anesthesia.

Its use is mandatory in the following cases:

• Treatment of pulpitis (first visit)
• Periodontal operations (closed and open curettage, gingivoplasty, elimination of gum recession, guided tissue regeneration)
• Prosthetics of vital (living) teeth with fixed structures (crowns, inlays, onlays, bridges)
• Tooth extraction, implantation, bone tissue augmentation, tooth-preserving operations (apex resection, root amputation, hemisection), making incisions for periostitis, pericoronitis, opening abscesses and phlegmons, removing cysts and tumors

In some situations, anesthesia is mainly used, but patients with reduced sensitivity can do without it:

• Treatment of caries, wedge-shaped defects, non-carious lesions, periodontitis

Procedures that most often do not require anesthesia, but particularly sensitive patients may require:

• Professional oral hygiene
• Restoration of pulpless teeth (both fillings and crowns or inlays)
• Removable prosthetics (if the gag reflex is increased, there may be a need for mucosal anesthesia)

Anesthesia is not recommended:

• Oral examination
• Preventive measures (fluoride varnish applications, fissure sealing)
• Teeth whitening
• Orthodontic treatment

Children often tolerate tooth preparation for caries much easier than an injection into the gum. Therefore, you should not necessarily give an injection on your first visit before starting treatment. It makes more sense to try drilling without anesthesia and switch to it only if the child complains of pain. Compassionate parents, do not worry that your child may experience hellish pain and refuse further treatment. Dentin sensitivity in children is less than in adults. The likelihood of getting psychological trauma from an injection is higher.

Diagnostic local anesthesia is used to identify the diseased tooth. When several adjacent teeth are severely damaged, it is difficult for both the patient and the doctor to determine the source of pulpal pain. In order not to depulpate them all, you can give one anesthesia and wait. If the pain has passed, it should be treated first; if not, anesthetize the next tooth and check the reaction.

Medical Internet conferences

Introduction. Most dental procedures are accompanied by pain of varying intensity to one degree or another. When performing work, dentists are often faced with a patient’s negative attitude towards treatment, fear and expectation of subsequent pain, and psycho-emotional stress. Up to 84% of patients experience psycho-emotional stress before dental surgery [2;3;6]. Improving painless techniques for the most common manipulations in dentistry, anesthesia and tooth extraction, is of great importance in overcoming the patient’s fear, which contributes to the establishment of contact between the doctor and the patient and effective treatment.

Purpose: to study and evaluate the effectiveness and safety of minimally invasive techniques of local anesthesia and tooth extraction according to literature data.

Tasks:

1) Identification of the relevance of using atraumatic technologies in dental appointments;

2) Study of the device and operating principle of the “Injector” device;

3) Study of the features of the use of Luxator periotomes;

4) Familiarization with the options for ultrasonic attachments for separation of periodontal ligaments;

5) Assessing the benefits of using ultrasonic instruments for atraumatic tooth extraction.

Materials and methods of research. During the work, the content of dental journals for the last 5 years, recommended by the Higher Attestation Commission, was studied, an analysis of domestic and foreign articles, as well as various websites and brochures was carried out.

Results and discussion. As pain relief methods improved, various models of syringes appeared, including modern needle-free injectors. In Russia, the study of the possibilities of using needle-free injectors for local anesthesia in dentistry began in 1972 [1]. An analysis of the literature showed that the use of needleless injectors was only an idea until recently.

In 2001, a new generation device “Injex” was created in Germany, very light (weighing only 75 g) and convenient to use. The injector consists of a stainless steel main body, a trigger mechanism and two safety valves. The injection ampoule with the required amount of anesthetic is inserted into the injector and screwed in until it stops. A special silicone Silitop attachment is placed on the ampoule, allowing the patient not to feel painful pressure on the gums. Then the dentist should firmly press the opening of the ampoule to the injection site at an angle of 90 degrees and, with a short press, activate the trigger mechanism. Using the energy of mechanical action, the spring and piston in the syringe quickly and smoothly push a thin stream of the drug through a microscopic hole (with a diameter of only 0.17 mm, which is twice as thin as the diameter of insulin needles) into the mucous membrane of the injection site. The injector ampoule holds up to 0.3 ml of anesthetic, which is enough for adequate pain relief. Anesthesia occurs immediately after the administration of the anesthetic, so you can begin dental treatment within the first minute of anesthesia. The duration of anesthesia is 20-25 minutes. Conducted studies indicate a preference for patients experiencing psycho-emotional stress, especially children, to use needle-free injectors for local anesthesia [4].

The most common dental surgery, along with local anesthesia, is tooth extraction. Indications for tooth extraction are very diverse, and therefore there is a need to choose the optimal method that will increase the safety of the operation, reduce the pain of the procedure and the amount of postoperative complications. During the analysis of articles, the two most common and effective atraumatic methods of tooth extraction were identified, namely the use of Luxator periotomes and the use of ultrasonic instruments. Luxator periotomes were invented and designed by Swedish dentist Ericsson. The entire operation is performed with minimal tissue damage, which promotes rapid healing, and the procedure itself becomes less tiring for both the patient and the dental surgeon [5; 8].

Luxator instruments are designed to cut periodontal ligament fibers. The shape of the tool resembles an elevator, but has a distinctive feature - a thin, tapering blade made of a very hard material. Thus, the instrument resembles a knife for cutting periodontal ligament fibers [7]. The instrument is used by a gentle rocking action to gently move the instrument tip within the tooth socket. Using a thin, sharp tip of the instrument, the fibers of the periodontal ligament are cut, pressure is applied to the alveolar bone, and the tooth is carefully removed from the dental socket. The use of this instrument helps preserve the surrounding bone tissue, accelerate the healing of the socket, and reduce postoperative pain and swelling.

In addition to the use of periotomes, the ultrasound method is used for atraumatic tooth extraction. At the moment, the use of ultrasound is the most advanced method of surgical operations. Various ultrasonic periotomes have been developed, differing in the length of the working part, its shape, and the angle of inclination. This variety allows the doctor to work in hard-to-reach places and perform complex tooth extractions with minimal impact on soft tissues and blood vessels. In addition, the use of ultrasound is accompanied by an antibacterial effect, which eliminates the possibility of the spread of infection. The ultrasonic tip is inserted parallel to the tooth root between the root cement and periodontal ligaments, then reciprocating movements are performed. In this way, the tooth is separated from the periodontal fibers and the tooth is removed.

Conclusions:

1) The use of the Injex needleless injector reduces patients’ fear of injection, improves the doctor-patient relationship and ensures the effectiveness of treatment, in addition, it reduces the likelihood of infection transmission through the needle and accidental injuries;

2) The use of luxators allows you to quickly and with minimal damage to the tooth socket perform a tooth extraction operation;

3) The ultrasonic method is most effective in cases of complex tooth extraction, has a variety of attachments for a variety of clinical cases, has an antibacterial effect, which prevents the spread of infections and is least likely to injure surrounding tissues.

Types of local anesthesia in dentistry

Superficial (application) anesthesia

It is carried out by spraying, irrigating or lubricating the mucous membrane with a topical anesthetic (most often lidocaine). The main advantage is that it is painless (no injection is required). However, it is only effective for soft tissue anesthesia. It does not reduce tooth sensitivity at all. Therefore, the use of only superficial anesthesia in the treatment of small carious cavities or ultrasonic teeth cleaning is unjustified.

Often used to reduce pain before an injection.

Application anesthesia helps patients with an increased gag reflex (when taking impressions, for example).

To remove mobile baby teeth in children, superficial anesthesia is sometimes sufficient, but if the roots have not yet completely resolved, then such anesthesia is not enough - infiltration anesthesia is necessary.

Lubricating with ointment is preferable to spraying with a spray because it is easier to control the area of ​​application. When splashed, the anesthetic can get onto the soft palate, creating discomfort and additional anxiety for the patient in terms of difficulty breathing (choking).

Infiltration anesthesia

It is carried out by injecting an anesthetic drug into the place whose sensitivity needs to be reduced. The anesthetic solution from the injection point spreads to nearby tissues (including dental nerves), temporarily eliminating pain and other sensations. When treating teeth, infiltration anesthesia is applied to the projection of the apexes (where the nerves enter the canals of the tooth). This type of anesthesia is preferred for the upper and lower anterior teeth. For lower chewing teeth, infiltration anesthesia is ineffective (due to the thick and dense bone tissue in this area).

The safest injection method of all. Possible minor complications include hematomas (bruises) and stomatitis at the injection site.

When anesthetizing single-rooted teeth (incisors and canines), one injection on the cheek side is sufficient. Multi-rooted teeth (molars and some premolars) require injections on both sides: buccal (labial, vestibular) and palatal (lingual on the lower jaw). On the palatal side, the injection is more painful than on the buccal side (since the mucous membrane of the palate is denser, and the injected solution injures the soft tissues more).

With periostitis, abscess and other acute inflammatory processes in soft tissues, the effectiveness of infiltration anesthesia decreases, and the pain of the injection increases. In such situations, conduction anesthesia is indicated.

Conduction anesthesia

It consists of blocking the sensitivity of the entire nerve trunk by introducing an anesthetic to the place where it exits the jaw to the surface. In this case, several teeth can be treated at once.

There are the following subtypes of conduction anesthesia in dentistry: mandibular and torusal (the lower teeth on one side are anesthetized), mental (lower premolars, canines and partially incisors), palatal (upper teeth on the palatal side), incisive (upper incisors and canines on the palatal side) , tuberal (upper molars on the buccal side), infraorbital (upper premolars and canines on the labial side).

Conduction anesthesia is not always successfully performed by the dentist. You have to do it again from time to time. Due to the technical complexity of the implementation: the doctor does not see the nerve trunk, the needle is brought to the average location of its location in the anatomical atlas, and a particular patient may have individual (quite different from the standard) anatomical features. The introduction of an anesthetic at a considerable distance from a large nerve does not allow achieving a complete block of sensitivity.

Even worse is a direct needle hit on a nerve during conduction anesthesia. In addition to sharp pain (as patients describe it - “electric shock”), subsequent loss of sensitivity is possible. Most often, mandibular or torus anesthesia is performed, so paresthesia of the tongue and lower lip (one half) is most common. Tingling, loss of taste, and discomfort may last for several weeks or months. Usually, sensitivity returns on its own without any manipulation, but in rare cases, paresthesia remains for life.

Therefore, conduction anesthesia is not recommended when safer infiltration can be used.

Intraligamentary anesthesia

It is carried out by injecting the drug into the periodontal ligament (located between the alveolus and gum on one side and the tooth on the other). To completely remove the tooth, several injections are required around the perimeter. Only one tooth is numbed. Effective for all teeth, but extremely painful. It is recommended to use it after preliminary infiltration anesthesia.

If the anesthetic is administered excessively, necrosis of the periodontal ligament (with subsequent tooth loss) is possible. If anesthesia is used to remove a tooth, this problem is irrelevant.

Intrapulpal anesthesia

It is carried out by injecting an anesthetic directly into the pulp of the tooth in case of pulpitis. This injection is very painful, so it is given only after preliminary infiltration, conduction or intraligamentary anesthesia. The tooth is still pre-drilled (otherwise you won’t be able to get to the pulp). The effectiveness is close to 100%, the analgesic effect does not last long, but usually this period of time is enough to remove the pulp.

Apart from pain, there are no complications.

Intraosseous anesthesia

It is achieved by introducing an anesthetic into the bone tissue surrounding the tooth after its perforation. Preliminary infiltration or conduction anesthesia is required. Due to the technical complexity of implementation, it is rarely used. Only if other types of local anesthesia have failed. About 90% effective, can block multiple teeth.

Modern anesthetic drugs in outpatient dentistry

Moscow Medical Academy named after. I. M. Sechenova

Department of therapeutic dentistry.

Elective abstract work on the topic:

Modern anesthetic drugs in outpatient dentistry.

Completed by: III year student, group 12

Faculty of Dentistry

Vyrypaeva Maria Glebovna

Teacher: assistant of the department Sokhova Inna Anatolyevna.

Content:

1. Introduction. Modern requirements for local anesthesia for dentists of all specialties. 2-4 pp.

2. Dosage forms of local anesthetic drugs and carpule technology. 4-7 pp.

3. Basic indicators of anesthesia when working with articaine anesthetics. 7-11 pp.

4. Conclusion 12 pages.

5. List of references used, 13 pages.

The problem of pain during various types of dental treatment has recently begun to be successfully solved with the advent of effective articaine anesthetics on the Russian market, but a number of problems associated with anesthesia remain unresolved, which make even experienced specialists worry:

1. the problem of guaranteed pain relief for all categories of patients;
2. problem of allergic reactions;
3. the problem of individual differences in anatomical structure, etc.

Many unnecessary problems and complications arise from the incorrect use of effective anesthesia techniques, which often arise due to neglect of the use of aspiration testing. It is also necessary to adequately select an anesthetic according to the individual characteristics of the patient and his predisposition to allergic reactions.

Modern requirements for local anesthesia for dentists of all specialties.

The requirements for local anesthesia put forward by dentists - therapists, surgeons and orthopedists - are similar. Currently, increased demands are placed on anesthesia in dentistry. Anesthesia must be predictable, i.e. the doctor performing the anesthesia must be confident that the anesthesia will work on any patient and that the pain relief will be sufficiently deep. In this case, it is necessary that the anesthesia lasts long enough, i.e., as long as the manipulation requires, and it is also desirable to avoid repeated injections and the effect begins as soon as possible. It is important that the injection itself is also painless.

Anesthesia must be safe for the patient, that is, it must not cause allergic reactions, must not be toxic, and have as few adverse reactions and complications as possible. Should be safe enough for patients at risk with concomitant diseases.

It should be noted that the entire complex of put forward requirements is realistically feasible. This depends on many factors: firstly, on the qualifications, knowledge and experience of the specialist, secondly, on the initial psychosomatic state of the patient, thirdly, on the competent choice of the drug for local anesthesia and premedication (if necessary), fourthly, on the chosen anesthesia technique, etc.

If you take the first four factors wisely, then the ineffectiveness of anesthesia, individual characteristics of the maxillofacial area, possible toxic reactions, dental phobia, bleeding, hematomas and other pressing problems will recede into the background.

To directly implement effective and safe anesthesia, you basically need good tools, i.e. carpule injectors and carpule needles that would fit their threads and would be easy to use, a reliable anesthetic and, most importantly, knowledge, skills and some experience in performing various methods of local anesthesia.

According to the results of Russian studies, as well as foreign ones, ultracaine preparations fully satisfy modern requirements for a local anesthetic. Its only drawback is the absence in Russia of dosage forms without a vasoconstrictor; therefore, it cannot be used in those categories of patients (about 2-5% of patients) for whom a vasoconstrictor is contraindicated. It should be noted that before using it, you must read the section in the information insert on contraindications (mainly related to the presence of a vasoconstrictor), which is written in Russian. If the information insert for any drug is written in a language other than Russian, this means that this drug entered Russia illegally, and you may have problems with its use.

Dosage forms of local anesthetic drugs and carpule technology.

Not so long ago, the technology of local anesthesia included the preparation of local anesthetics by diluting concentrated solutions of local anesthetics and adding, if necessary, vasoconstrictors directly in the medical institution. In this regard, responsibility for ensuring the correct execution of all stages of preparing solutions fell entirely on the employees of the institution. As experience has shown, in most cases the preparation of solutions was carried out with errors and inaccuracies due to the lack of special equipment, which led to complications when injecting such solutions into patients.

The development of carpule technology is a revolutionary achievement in our specialty. The transfer of the production process of local anesthetics to factory conditions ensured sterility and high accuracy in compliance with all production technologies. By visiting some manufacturing companies, you can see that the modern process of producing anesthetics is fully automated and controlled at all stages, from water purification to the dilution of vasoconstrictors. Thanks to this, the dentist can be completely confident in the quality of the local anesthetics used.

The introduction of carpule technology also made it possible to transfer responsibility for the quality of drugs administered from the carpule to manufacturing companies.

In this case, the doctor only needs to comply with a number of mandatory conditions, which include the following:

• the local anesthetic drug must be approved for use by the Pharmacological Committee of the Ministry of Health of the Russian Federation;
• The delivery package must include a certificate of conformity for this batch of the drug, confirming its quality based on an examination. The lot number of the drugs is indicated on each package and carpul;

You can purchase local anesthetic drugs only if the seller has the following documents:

• license for pharmaceutical activities, which indicates his right to trade;
• registration certificate of the Ministry of Health of the Russian Federation for this dosage form, which gives the right for its clinical use in Russia;
• certificate of the State Standard of the Russian Federation, which gives the seller the right to import the specified drug.

In the absence of one of these documents, legal responsibility falls on the doctor and the institution where the complication occurred from the use of the drug.

Carpool technology.

Carpool technology consists of the following main components:

• standardization of dosage forms of local anesthetic drugs;
• factory production of drugs in a ready-to-use form, which includes both a standardized solution and standardized packaging;
• techniques for injecting drugs using special instruments (syringes, needles) and the order of their use.

When preparing drugs independently, both the composition and concentration of substances included in the solution could vary within significant limits. For the most effective and safe drugs based on articaine, there are currently only two dosage forms that differ in the concentration of the vasoconstrictor: a 4% solution of articaine with adrenaline at a concentration of 1:100,000 or 1:200,000. For safety and ease of use of the anesthetic, ultracaine carpules and packages are produced with clear color differences:

• green color – Ultracain DS with a vasoconstrictor concentration of 1:200000;
• blue color – Ultracain DS forte with a vasoconstrictor concentration of 1:100000.

In addition to a local anesthetic and a vasoconstrictor in certain concentrations, solutions in carpules also contain other components. As a filler, pyrogen-free distilled water is used with the addition of sodium chloride to create osmotic balance: the pH of solutions varies from 3.0 to 6.0. To prevent oxidation of the vasoconstrictor (adrenaline), an antioxidant is added - sodium bisulfite solution.

The presence of a vasoconstrictor and antioxidant reduces the pH of the solution. In addition, during long-term storage, sodium bisulfite is converted to sodium bisulfate due to oxidation, which is an additional factor in reducing pH. The lower the pH of the solution, the more likely the patient will experience a burning sensation when the drug is administered.

The doctor must know the composition and properties of the components included in the carpuled solution. A description of the contents of the carpules is indicated on the box or in the information leaflet. This information includes data on the percentage of the solution, the trade name of the drug, the batch number, the name and address of the manufacturer, and the presence of a preservative. When using the drug, special attention should be paid to the shelf life, avoiding the use of expired drugs.

To preserve anesthetic solutions, methylparaben is most often used, which has bacteriostatic, antifungal and antioxidant properties. However, it is a strong allergen. Recently, most companies have switched to new technologies that make it possible to produce carpuled solutions without methylparaben. The absence of parabens has significantly expanded the indications for the use of carpules. EDTA (ethylene diamine tetraacetic acid) is added to the solution of some anesthetics. This preservative is usually added to the solution to leach it out and to bind into an inactive form the heavy metal ions that enter the solution from low-quality carpool glass. This preservative itself is non-toxic.

It should be noted that carpuled forms of ultracaine do not contain methylparaben and EDTA; they contain only the minimum required amount of sodium bisulfite to maintain vasoconstrictor activity.

Basic indicators of anesthesia when working with articaine anesthetics.

When performing various types of anesthesia on the upper and lower jaw with modern articaine anesthetics, it is necessary to take into account a number of factors: type of anesthesia, recommended needles for anesthesia, recommended dose of anesthesia, latent period, duration of anesthesia in minutes, success of anesthesia, list of manipulations that can be performed under this anesthetic.

These indicators were obtained thanks to research in this area and the experience of specialists. The tables below give the standards recommended for the use of modern carpule anesthetics of the articaine series.

The main indicators of anesthesia when working with an articaine anesthetic on the upper jaw using infiltration anesthesia.

List of procedures: surgical intervention on soft tissues, preparation of hard tooth tissues for a crown, cystectomy, opening of subperiosteal abscesses, treatment of periodontitis and depulpation, removal of one or more teeth, resection of the apex of the tooth root, osteostomy, restoration, implantation surgery, as well as all dental interventions for sanitation of the oral cavity.

The main indicators of anesthesia when working with an articaine anesthetic on the lower jaw with mandibular anesthesia (premolars and molars) and infiltration anesthesia in patients under 50 years of age (incisors and canines).

List of procedures: surgical intervention on soft tissues, preparation of hard tooth tissues for a crown, cystectomy, opening of subperiosteal abscesses, treatment of periodontitis and depulpation, removal of one or more teeth, resection of the apex of the tooth root, osteostomy, restoration, implantation surgery, as well as all dental interventions for sanitation of the oral cavity.

The main indicators of anesthesia when working with an anesthetic of the articaine series on the upper and lower jaws when using intraligamentary anesthesia.

List of procedures: treatment of caries and pulpitis, preparation of hard tooth tissues for a crown, tooth extraction for chronic periodontitis.

The main indicators of anesthesia when working with an anesthetic of the articaine series on the upper and lower jaws when using intrapulpal anesthesia.

List of procedures: depulpation and work with canals.

Conclusion.

After a detailed description of the most effective and safe methods of local anesthesia, I would like to dwell on an interesting observation. When surveying practicing dentists of various specialties: “What new things would you like to know in the field of local anesthesia?”, in most cases they were interested in information about new drugs. However, a new local anesthetic molecule appears once every 15-25 years, and a new dosage form of an old molecule appears once every 7-10 years. Currently, more than 100 drugs are used based on only 4-5 molecules (substances or active ingredients) with varying vasoconstrictor content.

The path to guaranteed and predictable anesthesia lies in increased attention and an individual approach to each individual patient, a thorough history taking, and the ability and willingness to provide the necessary emergency care measures. It is better to improve in methods and technologies of pain relief with the same drug from the articaine series, which is well known and studied, has a reliable carpule structure and a minimal amount of preservatives.

Bibliography:

1. “Modern methods of pain relief based on articaine-containing drugs” S. A. Rabinovich, M. V. Lukyanov, O. N. Moskovets, E. V. Zoryan OID “Media Press” LLC
2. “New in Dentistry” January 1999. Magazine.
3. “Practical therapeutic dentistry” A. I. Nikolaev, L. M. Tsepov, Moscow, “MEDpress-inform” 2003.
4. “Surgical Dentistry”, edited by T. G. Robustova, Moscow, “Medicine”, 2000.

10

Instruments for local anesthesia

The injection requires a syringe, a needle and a local anesthetic solution.

For several decades now, in dentistry, instead of disposable syringes, a reusable carpule syringe has been used. A disposable anesthetic cartridge and a disposable needle are inserted into it. They are used once, and the metal syringe itself is sterilized after each patient. Reuse of an incompletely used carpule is prohibited, since during the injection a reverse flow of blood or other liquid through the needle into the carpule is possible (there is a risk of infection of the next patient).

A special syringe gun is available for intraligamentary anesthesia. The same needles and carpules are inserted into it as into a carpule syringe. It allows you to more accurately dose the volume of anesthetic for a given type of anesthesia (but it is also possible to perform intraligamentary anesthesia with a regular carpule syringe).

The thickness of the needles used in carpule syringes is 0.3-0.5 mm. This is much thinner than disposable syringes (therefore the injection is much less painful). Length – 8-30 mm. For mandibular and torusal anesthesia, longer and thicker needles are used than for infiltration. To carry out intrapulpal and intraligamentary anesthesia, the needle can be bent (it does not break).

Carpula is a sealed glass cartridge with a rubber plunger. In dentistry, in most cases, the anesthetic solution, in addition to the anesthetic drug itself, contains a vasoconstrictor - a vasoconstrictor component that prevents the rapid elimination of the anesthetic through the general bloodstream. This is adrenaline (epinephrine). Its concentration is negligible - 1:100000 or 1:200000. When manually drawing such a mixture into a disposable syringe, add 1 drop of adrenaline to the anesthetic solution. However, the size of a drop is such a relative value that the concentration of this very active component can differ tens of times in different syringes. This creates many complications, even life-threatening situations for the patient.

The introduction of carpules with precise industrial dosages of components has greatly reduced the number of such complications. However, it should be noted that different manufacturers have different attitudes towards maintaining strict dosages of their own carpules. For the product of the Russian pharmaceutical industry, Brilocaine (manufacturer: Bryntsalovskiy Ferein), the anesthetic effect of two capsules from one package can be radically different: from complete absence of pain relief to super strong (“my legs froze,” according to the patient). Although the packaging states exactly the same ingredients as imported Ultracain, Ubistezin or Septanest.

Injection equipment for local dental anesthesia ru:12659

Injection equipment for local dental anesthesia The safety and effectiveness of local anesthesia in dentistry primarily depends on the equipment used for injection.

Injection equipment must meet the following requirements:

Cause minimal trauma to the patient.

Accurately deliver the anesthetic solution to the destination and create an anesthetic depot.

Precisely dose the anesthetic (up to 0.1 ml).

In dentistry today, various syringes are used that make it possible to perform both traditional anesthesia and intraligamentary, intraosseous, needle-free jet anesthesia, etc.

The injector most suitable for the use of modern carpule anesthetics is the carpule syringe.

Reusable carpule syringes are made of metal (stainless steel, titanium, etc.). We have also mastered the production of plastic carpule syringes - disposable and reusable.

The carpule syringe should be:

compatible with needles from different companies;

strong enough to administer anesthetics under pressure;

have an aesthetic appearance, be simple and convenient to use with one hand;

ensure an aspiration test.

A metal carpule syringe consists of a body 1 and a rod 2, which can have different shapes. As a rule, the body is cylindrical in shape with a window and has a side groove 4 (for placing the carpule). On the body there is a removable tip with nipple 3, with a thread for fixing (screwing on) the needle, two holders 6 (for the index and middle finger of the right hand) The holders can be either flat or in the form of rings. Rod 2 is made in the form of a rod with a plunger 8 at one end and a holder (ring) 7 (for the thumb of the right hand) at the second. The plunger can be in the form of a harpoon or “fungus”, or a hook and provides fixation of the carpule piston plug to ensure its reverse motion during an aspiration test.

If an anesthetic is accidentally introduced into a vessel, the toxicity of the anesthetic solution increases 10 times or more (especially if there is adrenaline in the anesthetic solution), and the patient experiences a general toxic reaction. Therefore, to prevent intravascular injection of an anesthetic, an aspiration test (test) is performed: before injecting the anesthetic solution, the syringe plunger must be pulled towards you. If the aspiration test is positive, you need to pull back the needle, then push it forward again.

Selecting a carpule syringe:

The injector should be simple and easy to use with one hand (the holder for the thumb of the right hand should be in the form of a ring).

There should be a window on the injector body to monitor the use of anesthetic and aspiration sample.

There should be a plunger at the end of the syringe plunger for performing an aspiration test.

The removable tip must have a threaded nipple for fixing different needles and the “American system”).

A cartridge syringe from Truewin Industries (Pakistan) meets all these requirements. The syringe is intended for local anesthesia in dentistry. The design of the syringe allows you to press on the rod and pull it back during aspiration with one hand. Truewin Industries Syringe Optimizes Aspiration Sample with Dual Locking Ring

The kit includes 2 replaceable nozzles for carpule needles according to American and European standards. To replace the carpule, it is necessary to pull the pusher back to its original position.

Very simple, reliable design, three ring-shaped finger grips. Made from particularly light alloy. Its coating is resistant to corrosion. The convenience of using this syringe lies in the fact that the anesthetic cartridge is installed into it very simply. Compatible with all standard cartridges (1.8 ml) with rubber piston. The rotating cartridge holder allows you to see the cartridge in any situation, especially when performing an aspiration test or monitoring the volume of injected solution. Simple disassembly of the syringe makes it easy to clean and sterilize the instrument.

Preparing the carpule syringe for use:

Sterilization of the injector in disassembled form (in an autoclave or in a dry-heat sterilizer, or “cold” sterilization). Sterilization by chemical means is carried out by complete immersion in a solution.

Sterilization of carpules. The carpule is wiped with gauze soaked in a 70° alcohol solution. It is necessary to properly process the rubber plugs.

The cartridge is inserted into the injector body

Press the injector piston so that the plunger is securely fixed in the piston plug of the carpule for carrying out an aspiration test

Select a sterile removable tip so that the thread of its nipple matches the thread of the desired needle. Remove the plastic cap from the rear (short) end of the needle and insert it into the nipple hole, at the same time screw the needle cone onto the injector nipple

Remove the plastic cap from the long end of the needle, pressing the syringe plunger, check the patency of the needle (drops of anesthetic appear at the end of the needle). The carpule syringe is ready for use

To carry out effective intraligamentary (infiltration) and intrapulpal anesthesia, special injectors are used, which create high pressure during injection. They also have a dispenser that ensures that a precisely defined amount of anesthetic is introduced into the tissue when pressing on the syringe lever.

Truewin Industries (Pakistan) injector, shaped like a pistol

This is a universal injector for all types of infiltration anesthesia with minimal doses of anesthetic, using a standard cartridge. Injects a small amount (on average 0.2 ml) of anesthetic per “click”, allowing for a slow, atraumatic injection. One injection is sufficient for intraligamentary anesthesia. Made from high grade stainless steel

The injector kit includes:

two removable tips for different types of carpule needles (European and American systems);

a protective cylinder for the carpule (made of plastic), it is put on the carpule before injection to prevent injury to the patient from glass fragments in case of possible rupture of the carpule during injection.

Preparing the injector for anesthesia:

The injector, replacement tips, protective cylinder and cartridge are sterilized.

A protective cylinder is put on the carpule and inserted into the removable tip (the thread of the nipple of the removable tip must correspond to the type of carpule needle - European or American system).

Screw the needle body onto the nipple of the removable tip, which, in turn, is fixed in the injector body.

Remove the plastic cap from the end of the needle, press the lever (trigger) - drops of anesthetic appear at the end of the needle. The injector is ready for use.

The shape of the injector is very convenient for anesthesia. One injection (0.2 ml of anesthetic) is sufficient for intraligamentary anesthesia into dense dental gums, and 0.4 ml of anesthetic (2 injections) qualitatively anesthetizes a single-rooted tooth with paraapical administration of the drug under the periosteum.

Needles for carpule syringes

Advances in science have led to needles becoming strong, flexible and sharp. These are disposable needles, which reduces the risk of infection entering the body and cross-contamination of the patient(s).

The carpule needle consists of a metal needle itself and a plastic connecting coupling (cone). The long end of the needle (for introducing anesthetic into the tissue) ends with a cut, the short end serves to pierce the carpule plug. The sharpness of the final cut of the needle allows you to minimize the pain of the injection.

The best companies put a mark (dot) on the outside of the cone with red paint on the cut side of the needle tip, which allows better orientation during anesthesia (when directing the cut of the needle to the bone).

Needles are divided by length into “long” (from 28.9 to 41.5 mm) and “short” (from 10 to 25.5 mm). Most companies produce standard needles with lengths of 12, 16, 25, 35, 38 mm

On the inside of the plastic cone there is a thread for screwing the needle onto the carpule syringe. The size (shape) of the cone depends on the type of needle: “European system” or “American system”.

Length, diameter of carpule needles in European and American systems:

Carpule needles are placed in a plastic case. During sterilization, a paper seal or control cut is applied, which seals the package. Needles are packed in a box of 100 pieces. The label indicates the name and address of the company, the type of needle, its length, the outer diameter (number) of the needle, the date of manufacture, and the shelf life. For example: 0.30x21 mm (diameter and length of the needle), 01.2015 (shelf life), Sopira (name of the manufacturer).

The use of carpule needles provides high-quality local anesthesia with minimal pain. It is better to buy needles in batches (packages). It is recommended to use needles only from well-known companies that guarantee high quality products.

A new brand in the field of dental anesthesia - SOPIRA needles (Heraeus Kulzer) - is a combination of many years of experience with the latest developments.

Precision, functionality and reliability are the high standard for SOPIRA carpule needles. The needles are characterized by first-class steel and an innovative needle cut. This solution meets all the requirements of a wide range of forms of dental anesthesia.

A special silicone coating makes it easier for the needle to penetrate the tissue.

Plastic connector with thread and needle bevel orientation indicator allows you to select the optimal direction of needle entry into tissue during injection

The triangular bevel of the needle tip helps reduce pain during injection.

The needles are compatible with all types of dental syringes on the dental market

The use of carpule needles from little-known and dubious companies can lead to complications (possible needle obstruction; fracture near the needle cone during anesthesia). In addition, the needle may not be sharp enough, which will lead to severe pain during the injection and injury to the periosteum.

The commercialization of the activities of dentists is increasingly increasing the requirements for anesthesia. In recent years, effective anesthesia has become a kind of calling card for a private practitioner. The complex that makes up the modern technology of local anesthesia, providing the dentist with effective and safe actions, is:

reliable modern anesthetics and vasoconstrictors

effective methods of local anesthesia

knowledge and practical skills on the full range of issues related to local anesthesia

reliable and convenient instruments (syringes and needles)

#Anesthesia

Ukr-Medmarket 5664 • 01/20/2015

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Local anesthetics

In Russia, 4 types of anesthetics are most widely used: novocaine, lidocaine, articaine and mepivacaine.

Novocaine (procaine) was synthesized in 1905 and became widespread throughout the world as the first non-narcotic anesthetic. It is a basic reference point - all subsequent anesthetics are compared in terms of effectiveness and toxicity with novocaine, whose indicators are taken as one. After the introduction of lidocaine, it lost popularity in developed countries. There is a high frequency of allergic reactions to novocaine.

Lidocaine was invented in 1943. Its effectiveness turned out to be 4 times higher than that of novocaine (with only twice the toxicity). Widely distributed throughout the world (1st place in the number of injections among anesthetics in the USA). However, like novocaine, it has a relatively high percentage of allergic reactions (including the development of anaphylactic shock). In addition, it is often used with increased concentrations of the vasoconstrictor 1:50000 and 1:25000, which increases its effectiveness, but increases the number of complications from the cardiovascular system. Indicated for pregnant women - FDA category B (see article Use of local anesthetics for dental treatment during pregnancy; safety for women in labor).

Articaine was synthesized in 1969. It began to be used in Germany, where it was registered under the commercial name "Ultracaine". This name of the drug is now no less popular than articaine, although it represents the product of only one, “Septanest”, “Alfacaine” and several other commercial names - this is the same as “Ultracaine”. The most common local anesthetic in Europe and Russia (it was approved in the USA only in 2000, 10 years later than here). 5 times more effective than novocaine. 1.5 times more toxic. According to the FDA classification, it is classified as category C.

Mepivacaine was developed in 1957. It is equivalent in effectiveness to lidocaine and inferior to articaine. It is noteworthy that, despite category C, it is often used for pregnant patients, due to the permission of non-adrenaline release forms (lidocaine and articaine carpules are sold only with a vasoconstrictor). Although in fact it is not the first choice drug for expectant mothers (see the article Is it possible to do local anesthesia during pregnancy?).

Adrenaline , also known as epinephrine, is not a local anesthetic, but is used in the vast majority of cases for dental injections. By narrowing the blood vessels, it helps preserve the anesthetic depot at the injection site, reduces its toxic effect on the body, and also reduces bleeding (which improves visibility during surgical procedures). Its use in pregnant women and patients with cardiovascular diseases (paroxysmal ventricular tachycardia, atrial fibrillation) is undesirable. Use with caution in patients with arterial hypertension, diabetes mellitus, and hyperthyroidism.

In addition to the anesthetic and vasoconstrictor, the solution may contain preservatives (methylparaben) and adrenaline stabilizers (sodium pyrosulfite). Both methylparaben and sodium pyrosulfite (metabisulfite) have a high frequency of allergic reactions, including the most dangerous - anaphylactic shock. This risk is significantly higher than that of the anesthetics themselves (and in principle there cannot be an allergic reaction to adrenaline). Therefore, methylparaben was completely abandoned in carpules - it is needed only when using large containers for preserving an unused solution after opening the ampoule. Sulfites are necessary to prevent the oxidation of adrenaline - they cannot be abandoned in carpules with a vasoconstrictor. Therefore, anesthesia without adrenaline is recommended for patients with multivalent allergies. The frequency (up to 5%) of sulfites provoking an attack of bronchial asthma is high, so anesthesia with adrenaline is also not recommended for asthmatics.

GBUZ LO "Tosnenskaya Clinical Interdistrict Hospital"

Pain during dental procedures is perceived by patients as a lack of professionalism or a dismissive, inattentive attitude of the doctor. Therefore, anesthesia in dentistry is considered one of the most important stages of treatment, which largely determines its overall effectiveness, as well as its attractiveness to the patient.

Anesthesia in dentistry can be carried out using one of three methods:

• local anesthesia: application, infiltration and conduction;
• general anesthesia - temporary reversible loss of consciousness and all types of sensitivity;
• Potentiated analgesia (sedation) is a combination of local anesthesia with systemic administration of a narcotic analgesic or anxiolytic.

Local anesthesia

Local anesthesia means turning off pain sensitivity in a limited area by blocking the pain impulse through nerve endings. The drugs act exclusively in the injection area, the patient remains conscious and fully controls his actions. Most dental procedures can be performed under local anesthesia.

Depending on the method of introducing the drug into the tissue, methods of local anesthesia are divided into three types:

• application - the anesthetic is applied to the surface of the skin or mucous membrane and penetrates deeper due to diffusion;
• infiltration – the anesthetic drug permeates the tissue layer by layer;
• Conductive: central and peripheral - a depot of an anesthetic solution is created in the area of ​​passage of a large nerve trunk.

Application anesthesia

The procedure is extremely simple: the anesthetic is applied directly to the skin or mucous membrane without violating its integrity. Preparations for local topical anesthesia in dentistry are produced in the form of gel ointments or concentrated solutions. In the first case, the surface to be numbed is lubricated; in the second, a cotton swab moistened with the drug is placed on it, or sprayed from a spray bottle.

The concentrated anesthetic, due to diffusion, penetrates 2-3 mm deep from the surface of the skin, blocking pain receptors of nerve endings. Pain relief occurs in approximately 3-5 minutes and lasts up to half an hour. The anesthetic substance is practically not absorbed into the blood, so this anesthesia technique is considered the safest.

Advantages of application dental anesthesia:

• painless during implementation;
• the effect occurs quickly;
• no resorptive effect is observed;
• minimal severity of side effects.

Flaws:

• shallow depth of anesthesia;
• short duration of action;
• impossibility of anesthesia of deeper tissues.

In what cases is topical anesthesia used?

• anesthesia of the injection site before injection anesthesia;
• removal of small neoplasms on a thin stalk located within the skin or mucous membrane;
• removal of dental plaque, periodontal applications;
• removal of baby teeth if the roots have already resolved and the crown is held on the mucous membrane;
• additional anesthesia of the pulp before its removal.

Infiltration anesthesia

This type of pain relief refers to injection techniques. The solution is injected deep into the soft tissues, saturating them. In this case, the nerve endings in the area of ​​drug administration are switched off and all tissues soaked in the anesthetic are anesthetized.

Advantages of infiltration anesthesia:

• good control of the anesthesia zone;
• rapid onset of anesthesia;
• satisfactory duration and depth of action.

Flaws:

• a large amount of anesthetic may be required if the anesthesia area is large;
• deformation of soft tissues due to the injection of anesthetic and swelling in the injection area.

Infiltration techniques in dentistry include the following types of pain relief:

• intramucosal and submucosal – provides anesthesia of the mucous membrane and periosteum. In the upper jaw, where the bone tissue is more porous, with the use of modern anesthetics with high penetrating power, the pain sensitivity of several teeth or jawbone can be switched off;
• subperiosteal and plexual - usually carried out after the submucosa, since the injection itself is painful and disables the pain sensitivity of bone tissue and the dental nerve (the solution penetrates deep into the bone due to diffusion);
• intraligamentary - an anesthetic solution is injected into the periodontal ligament connecting the tooth root to the bone socket. The pain sensitivity of the pulp of one tooth is turned off. The main advantages of this technique are deep local anesthesia, absence of numbness of nearby tissues, bleeding of the pulp (the best conditions for endodontic canal treatment) and the use of extremely small amounts of anesthetic – 0.1-0.5 ml.

• intraseptal and intraosseous anesthesia in dentistry involves the introduction of an anesthetic solution into the porous spongy bone. On the outside, it is covered with a dense cortical plate, which is almost impossible to pierce with a regular needle. Therefore, for intraosseous anesthesia, special thick needles are used or the cortical plate is trepanned using a bur. With intraosseous administration of an anesthetic drug, deep anesthesia of the bone and all teeth in the area of ​​drug administration is achieved, but this anesthesia technique is quite traumatic. Its use is justified during dental operations, in cases where the bone is already exposed during surgery.

Conduction anesthesia

In this case, a depot of an anesthetic drug is created in the area of ​​passage of a large nerve trunk, while the conduction of pain sensitivity is switched off and the analgesic effect occurs in the entire zone of its innervation. Conduction anesthesia in dentistry involves the use of small volumes of anesthetics in relatively high concentrations.

Large blood and lymphatic vessels usually run parallel to the nerve trunks and in close proximity to them. When administering an anesthetic, the doctor is guided by the location of anatomical landmarks, but does not see the nerves and blood vessels directly. The possibility of accidental damage is not excluded, but with strict adherence to the technique, it is reduced to a minimum.

Depending on the size of the nerve trunk, central conduction anesthesia and peripheral anesthesia are distinguished. In the first case, it means disconnecting the main nerve trunks directly at the point of their exit from the cranial cavity, in the second - smaller, secondary branches.

Advantages of conduction anesthesia:

• long-lasting and deep anesthesia in the area of ​​innervation of the trunk;
• a relatively small amount of anesthetic is required;
• allows you to achieve deep pain relief with the help of relatively ineffective anesthetic drugs.

Disadvantages of the technique:

• high risk of injury to nerves and blood vessels;
• requires a high level of manual skills;
• the area of ​​anesthesia is limited to the zone of innervation of the nerve trunk.

Types of central anesthesia

Anesthesia at the round opening of the skull - turns off the second main branch of the trigeminal nerve - the maxillary. In this case, the pain sensitivity of the alveolar process of the corresponding half of the upper jaw is turned off, along with all the teeth located in it and the mucous membrane covering it, as well as the skin of the wing of the nose and upper lip and the mucous membrane of the bottom of the maxillary sinus.

Anesthesia at the oval window - disables the pain sensitivity of half of the lower jaw on the corresponding side along with the teeth, as well as the mucous membrane of the cheek, floor of the mouth, half of the tongue, as well as the skin of the chin, corner of the mouth and lower lip.

Central anesthesia is used mainly by maxillofacial surgeons when performing volumetric interventions on the jaw bones.

Peripheral dental conduction anesthesia allows you to turn off sensitivity in the zone of innervation of one or more terminal branches:

• tuberal anesthesia - turns off the posterior superior alveolar branches and anesthetizes the chewing teeth of the upper jaw;
• palatal – anesthetizes the mucous membrane of the hard palate;
• infraorbital – turns off pain sensitivity in the area of ​​incisors and fangs, as well as the upper lip;
• incisive – anesthetizes the mucous membrane of the hard palate in the segment from canine to canine of the upper jaw.
• Toruval anesthesia turns off the inferior alveolar buccal and lingual nerves, anesthetizing all teeth of the lower jaw on one side, the mucous membrane of the alveolar process, cheek and tongue.

Local anesthetics

Local anesthetics, depending on their chemical structure, are divided into esters (novocaine, anesthesin) and amides (lidocaine, mepivastezin, articaine). The former are less toxic, the latter are more effective. In addition to the anesthetic itself, the composition of the drug may include vasoconstrictors and agents that improve the penetration of the solution into tissues. The main criterion for choosing a local anesthetic is the ratio of effectiveness and toxicity. From this point of view, the anesthetics of the amide group of the articaine series: Ultracaine and Ubistezin are considered the undisputed leaders.

The dentist himself decides how to numb the patient’s oral cavity during dental surgery. At the same time, it takes into account not only the performance characteristics of the anesthetic, but also its cost, as well as technical capabilities. For example, a doctor who knows the technique of conduction anesthesia can easily achieve a good level of pain relief with the help of lidocaine, but if there is a lack of manual skills, even the most effective articaine may not save you.

General anesthesia in dentistry

General anesthesia is a complex medical procedure that involves the use of potent pharmacological drugs, so it is not often used in dentistry. General anesthesia is indicated:

• patients with mental disorders, if it is impossible to establish productive contact with them;
• when performing extensive surgical interventions, most often in the area of ​​dental implantation;
• those who experience an irrational fear of dental intervention, which could not be eliminated after working with a psychologist and psychotherapist;
• treatment of pulpitis and periodontitis in young children.

When performing general anesthesia, the patient must be hospitalized for at least 1 day. Due to the large number of side effects and the impossibility of use in outpatient practice, anesthesia in dentistry is used less and less, giving way to intravenous sedation.

Potentiated analgesia

In this case, in addition to the local anesthetic, the patient is administered drugs that reduce anxiety.
In this case, the person remains conscious, aware of what is happening, able to follow the doctor’s instructions, but does not experience anxiety or fear of intervention. Coming out of the sedation state takes about half an hour, after which the patient can safely be sent home. Share news

Local anesthesia in pediatric dentistry

Local anesthesia is not recommended for young children under 2-4 years of age. Even if it is possible to fraudulently persuade a child to take an injection, after it, as a rule, he will no longer open his mouth for further treatment. Up to 6-7 years of age, the optimal method is infiltration anesthesia (including for the treatment of lower teeth). At this age, the lower jaw is not yet so dense and there is no need for conduction anesthesia. Of the drugs for children, the optimal choice would be articaine with a low adrenaline content of 1:200000 - since long-term manipulations are still contraindicated for children (they quickly get tired of the treatment), there is no need for long-term pain relief for many hours.

The effectiveness of local anesthesia

The success of deep anesthesia depends on the anesthetic, the concentration of the vasoconstrictor, the type of anesthesia, the dose of the drug, the qualifications of the dentist and the individual response of the patient. 4% articaine with an adrenaline concentration of 1:100000 is the most effective. Conduction anesthesia provides better pain relief than infiltration anesthesia, but requires a more highly qualified doctor. (However, even the most experienced specialists have a certain percentage of failures). The patient's agitated panic state and prolonged pain tolerance for several days before the visit reduce the effectiveness of local anesthesia. Alcohol and drugs - even more so.

Dosage

The volume of one carpule is 1.7-1.8 ml. This amount is enough for most manipulations within one or two teeth. When treating a larger number of teeth (especially if they are located far from each other), several carpules and injections into different parts of the oral cavity are required.

A second injection of anesthetic into the same place is carried out if the first one is unsuccessful or after some time, when long-term treatment has not yet been completed and the anesthesia begins to wear off. The introduction of the same drug can help if conduction anesthesia is ineffective the first time. With other types of anesthesia, it is necessary to change the anesthetic itself to a more powerful one. It is impossible to increase the volume of the injected solution indefinitely - in case of an overdose, a toxic reaction occurs. For articaine with adrenaline and lidocaine with adrenaline, the maximum dose is 7 mg/kg body weight. One carpule (1.7-1.8 ml) contains 34-36 mg of 2% lidocaine or 68-72 mg of 4% articaine. Therefore, for a person weighing 70 kg, the maximum number of carpules at one time is: 14 for 2% lidocaine and 7 for 4% articaine.

Coming time

Intrapulpal and intraligamentary anesthesia begins to take effect within a few seconds. Application, infiltration, intraosseous - after 1-5 minutes. Conduction anesthesia is the most variable - from instant pain relief at the same second (if the needle hits the nerve) to half an hour. Sometimes patients, rising from the dental chair after completion of treatment, claim that “only now the freezing has really taken hold.”

Soft tissues are anesthetized before teeth. If the lip or tongue is already “frozen,” the teeth may still remain sensitive, and their premature preparation will be painful.

Validity

The duration of anesthesia also depends on the anesthetic, the concentration of the vasoconstrictor, the type of anesthesia, the dose of the drug, the qualifications of the dentist and the individual response of the patient. Conduction anesthesia lasts up to 2-3 hours or more. Some patients note that the anesthesia wears off completely only in the evening (if the treatment was carried out in the morning). But this is with a strong anesthetic, a high concentration of adrenaline, a significant dosage, and close contact with the nerve trunk. In other situations, conduction anesthesia may not last even one hour. Infiltration anesthesia lasts 1 hour or less. Other types are even smaller.

If anesthesia does not work

Despite the proven effectiveness of modern painkillers, sometimes situations arise when anesthesia does not work on the patient. This may be due to the following reasons:

• Drinking alcohol on the eve of a visit to the dentist is often an obstacle to pain relief, since the ethyl alcohol contained in the patient’s blood blocks the action of the anesthetic;
• Taking an excessive dose of painkillers before dental treatment can also interfere with the normal action of the anesthetic. It is important that the patient's self-administered pain medications are largely eliminated from the body before visiting the dentist;
• It is also rare that a patient is individually immune to a particular drug.

In each specific case, the doctor will find out why the anesthesia is not working and offer alternative options. It is possible to postpone treatment to another day.