ESSAY
Local Anesthesia in Dentistry
Ritu Bahl
School of Dental Medicine, University of Connecticut Health Center, Farmington, Connecticut
This paper was the First Place winning paper of the ADSA Student Essay Award
Contest for 2003.
Pain and dentistry are often synonymous in the
minds of patients, especially those with poor den-
tition due to multiple extractions, periodontal disease re-
quiring surgery, or symptomatic teeth requiring end-
odontic therapy. Members of the public perceive a good
dentist as a practitioner who causes little or no discom-
fort. In turn, dental practitioners identify a good anes-
thetic as one that allows them to focus solely on oper-
ative procedures without distractions from pain-induced
patient movements. The everyday practice of dentistry
is therefore based upon achieving adequate local anes-
thesia.
Research has shown that the fear of pain associated
with dentistry is closely associated with the most com-
mon method for blocking pain during dental proce-
dures-intraoral administration of local anesthetics. This
is considered aversive due to the pain associated with
the injection and the perceived threat of needle punc-
ture prior to the injection.1 Another survey finding was
that those individuals who reported themselves as highly
fearful of dentistry were worried about receiving oral in-
jections and demonstrated an association between high
dental anxieties and missed or delayed appointments.2
Pain is a result of stimulation of nociceptors that are
receptors preferentially sensitive to a noxious stimulus
or a stimulus that will become noxious if prolonged.
When nociception reaches the cerebral cortex, it may
be perceived as pain. Pain may be abolished by inter-
rupting the pathways that carry the information of the
stimulus from the periphery of the body to the central
nervous system, by blocking the central nervous system,
or by removing the stimulus. Local anesthetics block
sensory neuronal conduction of noxious stimuli from
reaching the central nervous system.
Received June 20, 2003; accepted for publication July 12, 2004.
Address correspondence to Ritu Bahl, School of Dental Medicine,
University of Connecticut Health Center, 263 Farmington Avenue,
Farmington, CT 06030; bahl@student.uchc.edu.
Anesth Prog 51:138-142 2004
©) 2004 by the American Dental Society of Anesthesiology
138
NEUROANATOMY
The sensory supply to the teeth, jaws, and oral mucosa
is derived from the maxillary and mandibular division of
the trigeminal (fifth cranial) nerve, whose cell bodies are
found in the Gasserian ganglion. The maxillary nerve
carries purely sensory fibers, exits the skull through the
foramen rotundum, and enters the pterygo-palatine fos-
sa. At this point the maxillary nerve gives branches to
the sphenopalatine ganglion. Among the nerves that
pass through the sphenopalatine ganglion is the naso-
palatine nerve (also called the long sphenopalatine
nerve) that passes along the nasal septum and emerges
at the incisive foramen on the anterior hard palate. It
supplies sensation to the gingival soft tissues of the an-
terior hard palate. The greater and lesser palatine
nerves also pass through the sphenopalatine ganglion
and course through the greater and lesser foramina, re-
spectively. The greater palatine innervates the palatal
mucoperiosteum and the gingiva from the molars to the
area near the cuspid region that abuts tissue supplied by
the nasopalatine nerve. The lesser palatine nerve sup-
plies the tissues of the soft palate and uvula. The max-
illary nerve also gives rise to the posterior superior al-
veolar nerve, which supplies sensation to the buccal gin-
giva and periodontium adjacent to the maxillary molar
teeth and the pulps of all molar teeth except the mesio-
buccal pulp of the upper first molar. That mesio-buccal
pulp is supplied by another branch of the maxillary
nerve, the middle superior alveolar nerve, which also
innervates the pulps, buccal gingiva, and peridontium of
the maxillary premolars. The final branch of the maxil-
lary nerve, the anterior superior alveolar nerve, supplies
the pulps of the upper incisors and cuspid along with
the associated buccal gingiva and periodontium.3,4
Unlike the maxillary division, the mandibular division
of the trigeminal nerve is a mixed motor and sensory
nerve. The mandibular nerve exits the skull through the
foramen ovale to enter the infratemporal fossa. It then
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Anesth Prog 51:138-142 2004
Chemical Classification and Duration of Action of Local Anesthetic Agents
Local Anesthetic Classification
Lidocaine Amide
Prilocaine Amide
Mepivacaine Amide
Bupivacaine Amide
Etidocaine Amide
Articaine Amide with an ester side chain
Procaine Ester
divides into anterior and posterior divisions. The ante-
rior division has some sensory branches: the long buccal
nerve that supplies the buccal mucosa and the gingiva
adjacent to the lower molar and second premolar teeth.
Other fibers supply sensation to the skin of the cheek.
The posterior division is primarily sensory. It branches
to give the auriculotemporal, lingual, and inferior alve-
olar dental nerves. The lingual nerve innervates the lin-
gual gingiva, floor of the mouth, and anterior two thirds
of the tongue. The inferior alveolar nerve supplies sen-
sation to the pulp and periodontium of all the molar and
premolar teeth on 1 side of the mouth. Near the mental
foramen, the inferior alveolar nerve branches into the
incisive and mental nerves. The mental nerve innervates
the buccal gingiva and the mucosa from the mental fo-
ramen forward to the midline, including the skin of the
lower lip and chin. The incisive nerve supplies the pulps
of the first premolar, canine, and incisor teeth.3,4
LOCAL ANESTHESIA
Local anesthesia is defined as a loss of sensation in a
circumscribed area of the body by a depression of ex-
citation in nerve endings or an inhibition of the conduc-
tion process in the peripheral nerves. In clinical practice
a localized loss of pain sensation is desired. Although
the terms dental anesthesia and dental analgesia are
used synonymously in dentistry, local analgesia is more
accurate. Local anesthesia can be achieved by a number
of mechanisms including mechanical trauma, anoxia,
and use of neurolytic agents in addition to traditional
local anesthetic drugs. However, clinically only reversible
local anesthetic agents and other reversible techniques
such as temperature reduction or electronic stimulation
are useful to prevent pain.
The use of reversible local anesthetic chemical agents
is the most common method to achieve pain control in
dental practice.5 Some ideal properties of local anes-
thetics are as follows:
* Specific action
* Reversible action
Bahl 139
Duration
Intermediate
Intermediate
Intermediate
Long-acting
Long-acting
Intermediate
Short-acting
* Rapid onset of action
* Suitable duration of action
* Active whether applied topically or injected
* Nonirritant
* Causes no permanent damage
* No systemic toxicity
* High therapeutic ratio
* Chemically stable and a long shelf life
* Ability to combine with other agents without loss of
properties
* Sterilizable without loss of properties
* Nonallergenic
* Nonaddictive
In spite of the major advances made in the field of an-
esthesia, the ideal local anesthetic agent does not exist.
Local anesthetic agents can be classified in several
ways (as shown in the Table):
* Chemical structure: local anesthetics are classified
usually as either esters or amides.
* Duration of action: local anesthetics maybe classified
as short acting, intermediate-acting, or long-acting.
The injectable local anesthetics used in dentistry have a
common core structure consisting of5,6
* Hydrophilic amino terminal
* Intermediate chain
* Lipophilic aromatic terminal
The combination of hydrophilic and lipophilic prop-
erties in 1 molecule is essential for an injectable local
anesthetic to be effective. The hydrophilic portion of the
molecule consists of a substituted secondary or tertiary
amine. Solubility in water is essential for 2 reasons-to
allow for the dissolution in a solvent to permit injection,
and to allow penetration through interstitial fluid follow-
ing administration.5,6
The intermediate chain consists of either an amide or
ester linkage. This allows spatial separation of the hy-
drophilic and lipophilic components of the molecule.
The older agents, procaine and cocaine, are ester-based
140 Local Anesthesia in Dentistry
drugs but are no longer widely used as dental anesthetics
due to their unwanted side effects, such as toxic or al-
lergic reactions.
The lipophilic part of the local anesthetic agent is an
aromatic residue that is essential for its ability to pene-
trate fatty tissue such as the lipid sheath of nerves in
order to gain access to the nerve cell membrane to
reach its site of action.
Different drugs have different proportions of hydro-
philic and lipophilic components. These differences
modify the characteristics and/or the properties of the
anesthetic agents in the following ways:
* Intrinsic anesthetic potency: the minimum concentra-
tion of local anesthetic required to reduce the nerve
amplitude by half its amplitude within 5 minutes. It is
a measure of pharmacologic action of the agent.
* Onset of anesthesia: the onset of anesthesia is de-
pendent on the speed at which the agent passes
through the tissue, the proximity of site of injection
to the nerve to be anesthetized, and the diameter of
the nerve fibers. Thin fibers are anesthetized more
rapidly as compared with thick fibers, possibly be-
cause the nodes of Ranvier are closer together.
* Duration of action: duration of action of anesthesia is
dependent on the rate of diffusion along a concentra-
tion gradient away from its site of action-the ion
channels in the nerves.
* Effects on other tissues including toxicity: the func-
tions of lipid-containing organs and tissues such as
the brain and heart may be affected by high levels of
local anesthetics.
* Rate of degradation, both systemically and locally:
most amide local anesthetic agents are broken down
by hepatic dealkylation and hydrolysis and are sub-
sequentially conjugated with glucuronic acid and ex-
creted in the urine. Esters are metabolized by ester-
ases that are widely distributed in the body.
The general constituents of a dental cartridge of anes-
thetic solution are:
* Local anesthetic agent
* Vasoconstrictor: this is sometimes included to delay
the removal of the anesthetic from the tissues by de-
creasing the blood flow through adjacent blood ves-
sels. A vasoconstrictor produces the following advan-
tages: (a) longer duration of local anesthetic action,
(b) reduced bleeding of a surgical site, and (c) reduced
systemic effects. The most commonly used vasocon-
strictors are epinephrine (adrenaline) and octapressin
(felypressin). Only epinephrine is available in the Unit-
ed States.
* Reducing agent: this prevents oxidation of the vaso-
Anesth Prog 51:138-142 2004
constrictor and acts by competing with the vasocon-
strictor for oxygen available in the solution. The most
commonly used reducing agent is sodium metabisul-
fite.
* Preservative: a bacteriostatic preservative prolongs
the shelf life of the solution, but since preservatives
can provoke allergic reactions, they are no longer
contained in dental local anesthetic cartridges in the
United States. The typical shelf life of an anesthetic
without preservative is approximately 18 months to
2 years.
* Fungicide: Thymol is used occasionally as a fungicide.
* Carrier solution: an acidic aqueous solution dissolves
the local anesthetic salt and maintains it at an ac-
ceptable pH.
MOLECULAR BASIS OF LOCAL ANESTHESIA
All local anesthetic agents used in dentistry work by ob-
structing the exchange in Na+ permeability, which is es-
sential for the initial phases of a neuronal action poten-
tial. This mechanism prevents the development and
propagation of the action potential by preventing the
wave of depolarization.
FAILURE OF ANESTHESIA
Failure of local anesthetics to achieve profound anal-
gesia may be related to:
* inaccurate anatomic placement of local anesthetic so-
lution
* placing too little solution
* allowing insufficient time for it to diffuse and take ef-
fect
* injecting into inflamed or infected tissues
* using an outdated or improperly stored anesthetic so-
lution.
It is recommended that a local anesthetic not be injected
in infected tissue because of the risk of spreading the
infection and the increased probability of achieving less
than effective anesthetic results owing to the low pH
within the infected tissue maintaining the ionized, non-
lipid-soluble state to the anesthetic.
COMPLICATIONS OF LOCAL ANESTHETICS
Complications of local anesthetic administration include
both local effects and systemic effects.7 Local compli-
cations include:
Anesth Prog 51:138-142 2004
* Spread of infection: occasionally infection may be
spread into the tissues by the needle passing through
a contaminated tissue or by the needle being contam-
inated before use.
* Hematoma: damage of a blood vessel by the tip of a
needle may lead to bleeding into the tissues, resulting
in the formation of a hematoma. Significant bleeding
may produce swelling, act as an irritant to the tissues,
and cause pain and trismus. Theoretically, the local-
ized collection of blood becomes an ideal culture me-
dium for bacteria, although infection of a hematoma
is unusual.
* Nerve damage: rarely, during an injection the needle
may pierce a nerve bundle during placement, pro-
ducing an immediate electric shock sensation to the
patient. It is usually followed by a partial sensory def-
icit, but subsequently a complete return to normal
sensation usually follows.
* Blockade of the facial nerve: if the injection is given
in close proximity to the facial nerve, a motor block-
ade causing temporary paralysis of the muscles of fa-
cial expression may occur. The effect may last for 1-
2 hours. In such circumstances, the desired branch of
the trigeminal nerve will not be anesthetized, and a
subsequent injection will be required at the correct
anatomic location to achieve the desired effect.
Systemic complications include:
* Regional or systemic infection: the spread of infection
within the perioral tissues can be potentially spread
through planes of the head and neck by passage of a
needle through an infected area.
* Endocarditis risk: injections such as the intraligamen-
tary injection can force bacteria into the systemic cir-
culation and cause bacterial endocarditis.
* Cardiovascular disease: patients with ischemic heart
disease (angina pectoris, previous myocardial infarc-
tion) or who have had previous cardiac surgery or
circulatory dysfunction such as cardiac failure, show
higher plasma levels of lidocaine when compared
with healthy subjects given the same dose. Therefore
it is recommended that the maximum safe dose be
halved in such patients.8 Low plasma potassium levels
and acidosis also potentiate adverse effects of local
anesthetics on the myocardium.7
* Liver disease: patients with reduced hepatic function
may exhibit an abnormally decreased rate of metab-
olism of amide local anesthetics, resulting in poten-
tially toxic blood levels. Dosage levels must therefore
be reduced for these patients.
* Pseudocholinesterase deficiency: local anesthetics of
the ester type (eg, procaine) should be avoided in pa-
tients who have this rare familial enzyme defect as
Bahl 141
metabolism of these drugs is impaired. Ester-type lo-
cal anesthetics are no longer routinely used for dental
procedures.
* Methemoglobinemia: this is a rare complication
caused by a metabolite of prilocaine that oxidizes the
ferrous component of heme in red blood cells to the
ferric state. This reduces their oxygen-delivering ca-
pacity and results in tissue hypoxia.
USE OF LOCAL ANESTHETICS DURING
PREGNANCY
The adverse drug reactions during pregnancy may affect
either the mother or the fetus. Hypersensitivity, allergy,
or toxicity reactions in the mother may compromise her
health and limit her ability to support a pregnancy. For-
tunately, doses of local anesthetics in dentistry are usu-
ally relatively small and are generally unlikely to cause
complications during pregnancy. All local anesthetics
cross the placenta to some degree.9-11 Highest concen-
trations in the fetal circulation follow injection of prilo-
caine, and the lowest follow bupivacaine, with lidocaine
in between.12."3
Felypressin, which is a derivative of vasopressin and
is related to oxytocin, has the potential to cause uterine
contractions. Although this is a highly unlikely effect at
the low dose of felypressin used in local anesthetics, it
is best avoided during pregnancy. Lidocaine with epi-
nephrine is commonly used for pregnant dental pa-
tients.
The performance of common dental treatments for a
pregnant patient is highly variable. In a telephone survey
using a standardized questionnaire, 78 resident dentists
in Germany, Switzerland, and Austria were interviewed
with respect to several aspects of the dental treatment
of pregnant women. Only 58% of the interviewees de-
cided clearly in favor of using local anesthetics, 59%
supported the use of analgesics, 70% supported a pos-
sible antibiotic therapy, and 33% would agree with a
radiological examination during pregnancy.9"13 In addi-
tion, according to references in the specialist literature,
guidelines for the dental treatment, drug therapy, and
radiological diagnosis of pregnant women are present-
ed.12 The local anesthetics should have a high plasma
protein bonding capability (Articaine, bupivacaine, eti-
docaine) and minimum epinephrine concentrations.
Acetaminophen is the usual analgesic of choice for
pregnant dental patients. If an antibiotic treatment is re-
quired, penicillin, cephalosporin, and erythromycin are
recommended. In particular, during the first 3-month
period, radiological examinations should be restricted to
the absolute minimum and performed only if no rea-
142 Local Anesthesia in Dentistry
sonable alternative is available, although the radiological
burden on the fetus falls 500,000 times short of the
limit value of 50 mgray (5 rad) in the case of a micro-
radiogram, and 50,000 times short of the limit value in
the case of an orthopantomogram.2
LOCAL ANESTHETICS IN CHILDREN
Fixed pediatric dosage recommendations for a given age
range are no longer endorsed for local anesthetic and
sedative agents. Available data suggest that adverse re-
actions in pediatric patients are commonly caused by
inadequate dosage reduction.14 Maximum recommend-
ed doses of local anesthetics is based upon the weight
of the child, usually expressed as milligrams per kilo-
gram of body weight. For very obese children, the max-
imum dose should be calculated on the basis of lean-
body weight or ideal weight, not the true body weight.
The specific number of milligrams per kilogram used for
calculating the maximum recommended dose differs
among the various local anesthetics.
MEDICAL-LEGAL CONSIDERATIONS
It is incumbent upon every dental practitioner to treat
his or her patients in an appropriate way, taking into
consideration both their dental needs and any special
precautions related to their past medical history. To pre-
vent any implication of negligence, a practitioner must
administer appropriate treatment. Furthermore the pa-
tient should receive adequate information about the pro-
posed dental treatment and must submit themselves will-
ingly to a local anesthetic as a part of the proposed
dental treatment after the benefits and risks are ex-
plained. Medico-legal complaints arising from adminis-
tration of local anesthesia are few in number. There are,
however, some particular complications arising directly
from the local anesthetic drugs or their delivery that
merit consideration.
Persisting anesthesia or paresthesia due to damage to
various branches of the trigeminal nerve is a common
complication in dental surgical procedures, especially
associated with lower third molar removal. Cases relat-
ing to sensory loss of lingual nerve and inferior alveolar
nerve following inferior dental block injections for re-
storative procedures have occasionally been presented
as a legal complaint.
In a study of over 12,000 inferior dental block injec-
tions, all given for restorative treatment, 18 patients
Anesth Prog 51:138-142 2004
(0.15%) were found to have some lingual sensory dis-
turbance following treatment. Of these 18 patients, 17
patients totally regained normal sensation within 6
months, and 1 patient still had a loss of sensation after
1 year (0.008%). Of the 12,000 patients, 856 (7%) ex-
perienced an "electric shock" type feeling in the tongue
at the time of injection, suggesting that the tip of the
anesthetic needle had touched the lingual nerve.3
Although the medico-legal issues tend to frighten the
dental practitioner, statistical data demonstrate that if
the current standards of practice are observed, the den-
tist is unlikely to run into these types of problems.
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