More than thirty years have passed since the collapse of the Soviet Union, a lot has changed in medicine for the better, and people are still afraid to go to the dentist, remembering themselves or having heard from others how painful and unpleasant it is.
Anesthesia in Soviet dentistry was indeed a “weak link”, and many manipulations in the dentist’s chair were done without pain relief at all. However, now the situation has become much better, including thanks to the penetration of foreign drugs and technologies into our market.
The usual injection has been replaced by many different techniques. Of course, it’s still difficult to call a visit to the dentist pleasant, but it has definitely become much more comfortable.
Anesthesia
Modern anesthesia not only eliminates the patient’s physical pain during procedures, but also reduces his psycho-emotional stress - eliminates the fear of the doctor, which significantly increases the efficiency and quality of the specialist’s work.
Local anesthesia in dentistry: types and preparations
In dentistry, both therapeutic and surgical, different types and techniques of anesthesia are used, for example, conduction, infiltration, intracanal, intraosseous, intraligamentary (intraligamentous), tuberal and others. Their differences lie in the place of application and in some features of their effects. As a rule, modern dental clinics in Moscow use carpule anesthesia. This means that the anesthetic is supplied in disposable carpules - a kind of cartridges with an anesthetic solution that are inserted into syringes with screw-on disposable needles. Due to this, the carpules remain sterile, since the dentist does not have to open them, thereby eliminating contact of the medicine with air.
How does the patient feel?
When the tissue is pierced with a needle, the patient will experience discomfort and mild pain. The severity of this pain symptom does not exceed the pain felt when taking blood for examination.
The drug is administered slowly, and at this moment the patient may experience fever, slight dizziness, and bloating from the inside. These unpleasant sensations disappear after a few seconds.
When the anesthesia begins to take effect, the patient experiences increasing numbness of the lips. Conduction anesthesia guarantees the absence of discomfort and pain when performing any dental procedure, during which the patient remains conscious. At his request, this anesthesia can be combined with sedation.
Conduction anesthesia
Conduction anesthesia is aimed at blocking the nerve through which the pain signal is transmitted. In this way, it is possible to “turn off” a significant area of the jaw associated with the nerve that was exposed to the drug for a fairly long time - from an hour to an hour and a half. As a rule, conduction anesthesia is prescribed if extensive intervention is required on several molars and adjacent soft tissues. With the conduction method, the anesthetic is administered in close proximity to the nerve, and it is very important to correctly calculate this location, since if it is too far from the nerve, pain relief may not occur, and if it gets into the nerve itself, a complication such as neuropathy may develop . According to statistics, neuropathy occurs in 1% of cases and most often completely recedes within a year. By the way, when conducting conduction anesthesia in dentistry under ultrasound guidance, its safety and effectiveness are significantly increased.
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.
Topical anesthesia in dentistry and drugs
Infiltration or application anesthesia in dentistry is carried out by soaking soft tissues with an anesthetic solution, as a result of which the nerve endings located in the treated area are blocked. With topical anesthesia, the anesthetic is applied without the use of a syringe. Using a cotton swab or your fingers, apply a small amount of the product, which subsequently penetrates approximately 3 mm inside and numbs the selected area. In dentistry, it is used to perform simple and quick operations associated with anesthesia of the oral mucosa, since it lasts, on average, from 10 to (in rare cases) 25 minutes. It is often preceded by subsequent injection anesthesia, especially if the patient is a child or is afraid of injections. There are also preparations for topical anesthesia in the form of aerosols. They are not widely used in dentistry due to difficulties in calculating dosage, as well as easy penetration into the respiratory tract and bloodstream, which increases the risk of complications.
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.
Infiltration anesthesia
This is one of the most common methods of anesthesia in modern dentistry. There are two types of infiltration anesthesia: direct and indirect. Direct anesthesia is injected directly under the mucous membrane near the teeth that require treatment, and acts at the injection site. Indirect spreads to surrounding tissues and covers a larger area, while its prevalence depends on the type of surrounding tissues. For example, on the upper jaw the alveolar process is more porous, while on the lower jaw it is denser, which means that the effect of infiltration anesthesia on the upper jaw will be more effective.
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.
Intraligamentary anesthesia
Intraligamentary anesthesia is also called intraligamentous and intraperiodontal. Its difference is in higher pressure when administering an anesthetic, which ensures uniform spreading of a small amount of the drug in the periodontal space, as well as its penetration into the intraosseous space. Drugs should be administered very slowly. When using this type of anesthesia, significantly less drug is required than with conventional infiltration; it occurs within 15-45 seconds and lasts for 20-30 minutes. For intraligamentary anesthesia, special syringes are often used, which make it possible to administer the drug under the required pressure without unnecessary effort and thus achieve the best result.
Intraosseous anesthesia
Intraosseous anesthesia in dentistry is chosen when infiltration or conduction anesthesia is ineffective. It is usually performed in the area of the lower molars and is indicated for treatment, tooth extraction and operations on the alveolar process. However, it is rarely used due to the complex technique of execution: it is necessary to dissect the mucous membrane, then make a hole in the bone with a special bur with a diameter equal to the size of the syringe needle in order to direct the syringe directly to the spongy substance. The drug should be administered slowly, under high pressure.
Among the advantages of this type of anesthesia is significant efficiency; a small amount of even a weak anesthetic is sufficient. Among the disadvantages are the complexity of implementation, as well as serious risks of complications if the drug enters the bloodstream, which is likely due to accidental damage to a vessel.
Features of conduction on the lower jaw
The distribution of the medicinal drug is difficult in this part of the face, so intraoral (torusal, mental) and extraoral (mandibular) pain relief techniques are used.
Mandibular
The needle is inserted on the border between the middle and pterygoid mandibular folds. During injection, the syringe is located at the level of the lower opposite premolars.
The needle is inserted to the bone (2 - 3 cm), then 1 - 2 ml of the drug is slowly poured in. Next, the syringe is moved to the opposite side, advanced 1 - 2 cm, and when resting on the bone, another 1 - 2 ml is poured.
Numbness usually begins within 10 minutes (the time depends on the anesthetic used) and simultaneously affects the lingual and alveolar nerves, canines, molars and premolars, mucous membrane, part of the tongue and the lower lip.
Torusal
With this method, the buccal nerve is additionally blocked. The placement of the syringe is identical to mandibular anesthesia.
The drug is injected into the area where the lingual and buccal nerves are located. The needle goes 2 cm deep, the anesthetic is injected, and then slowly pulled out halfway and another 1 ml is injected. The second injection is necessary to block the lingual nerve.
Mental
Used to relieve pain in the front of the jaw. The needle is inserted into the fold located at the height of the first molar. It moves inward—forward—downward.
The drug is infused (0.5 - 1 ml) at the height of the upper part of the root of the second premolar. At the same time, fangs, incisors, premolars, mucous membranes, lips, alveolar, and chin are anesthetized.
Due to the structural features of the jaw and the presence of inflammation on the mucous membrane, patients are more likely to undergo mandibular anesthesia.
Anesthesia of the lower jaw is described in detail in the video.
Intracanal anesthesia
The intracanal method of pain relief speaks for itself. Typically, intracanal anesthesia in dentistry is carried out in this way: using a drill, a hole is made in the tooth corresponding to the diameter of the needle, and the drug is injected directly into the pulp or deeper into the canal. Sometimes the carious cavity itself is used for this. If we are talking about the intraligamentary technique, then we mean the introduction of a local anesthetic solution into the space at the root of the tooth (periodontal), and the tuberal technique means the introduction of a substance into the posterior alveolar branches of the upper jaw.
Tuberal anesthesia
Tuberal anesthesia is so named in connection with the injection site - the tubercles of the upper jaw, which are called tuber in Latin. The posterior alveolar nerves are located here, innervating the area of the alveolar ridge from the third to the first molar. This type of anesthesia is the most dangerous in terms of possible complications due to individual differences in the structure of this area and the location of nerves and blood vessels in it. There are intraoral and extraoral methods of administering tuberal anesthesia. It is believed that the intraoral method is more likely to cause injury, while the external method is safer and it is also easier to ensure adequate antiseptic treatment of the surface before injection.
Computer anesthesia
Computer anesthesia allows dentists to calculate more accurate doses of the drug, administer it at the desired speed, pre-selected by the computer, and painlessly guide the syringe needle, which has a special cutting edge. Anesthesia administered with high precision can last longer - up to 40 minutes, and visual and audio signals provided by the device allow the doctor to position the needle as needed, without the risk of tissue damage, introducing anesthetic into the bloodstream or placing the needle too far from the nerve.
Ultrasound anesthesia
When performing anesthesia, it is very important to choose the right injection site, since a mistake can lead to serious complications. This is especially true for conduction anesthesia, where the drug must be in close proximity to the nerve, but the needle cannot touch it. Ultrasound successfully helps determine the site of anesthetic injection. Under the control of an ultrasound machine, it is possible to calculate down to the millimeter the location of the needle and its proximity to the nerve, thereby ensuring the most effective and safe anesthesia of the desired area.
Possible complications
In the practice of specialists at the World of Dentistry clinic, severe complications after conduction anesthesia occur in extremely rare cases. Negative effects include neuropathy and an inadequate response of the body to the administered drug. Complications that are normal and go away on their own include:
- Muscle weakness.
- Goosebumps effect.
- Partial loss of sensitivity.
The above symptoms disappear without a trace a maximum of a month after the procedure. Damaged nerves are completely restored.
General anesthesia in dentistry
In some cases, the patient may require dental treatment under general anesthesia. As a rule, it is used when serious and long-term treatment is necessary, for example, the removal of several teeth at a time or complex operations on the jaw. An indication for the use of general anesthesia in dentistry may also be serious dental phobia or a disease in which a person cannot adequately communicate with the doctor, or he may have unexpected reactions to the doctor’s actions, as, for example, with epilepsy.
As an alternative to general anesthesia to correct mood and relieve fear of dental treatment, there is sedation in dentistry. It does not “turn off” consciousness, but puts you into half-asleep and calms you down, helps you relax, and perceive what is happening in a positive way. However, sedation is not anesthesia, so it is used in combination with local anesthesia.
How to improve the quality of pain relief?
The patient, for his part, can also prepare for the upcoming intervention and thereby improve the quality of pain relief. To do this you need to follow these simple rules:
- Postpone a visit to the dentist if you have infectious diseases or (for women) during menstruation.
- Be sure to inform your doctor about allergic reactions to medications.
- The day before visiting the dentist, refrain from drinking alcohol and visiting the sauna.
- The evening before your visit, you may take a small dose of a sedative to relieve tension.
When is anesthesia used in pediatric dentistry?
Most adults have a fear of dental treatment left over from childhood, so today one of the tasks of a pediatric dentist is to prevent the occurrence of dental phobia or get rid of fears that have already formed in the child. General anesthesia is often the only way to solve dental problems in children under three years of age, as well as in children with developmental disabilities, in particular with autism, Down syndrome, cerebral palsy or epilepsy.
It is not always necessary to carry out dental treatment in children under anesthesia. A small patient who comes to a kind and open doctor will be able to perform most of the manipulations while conscious. The main condition is that these manipulations must be painless. According to some studies, today the most painful procedure for a child is the anesthetic injection itself. That is why in pediatric dentistry, before an injection, topical anesthesia is used, the preparations for which have a pleasant taste, which contributes to a good mood in children and their cooperation with the doctor.
In addition, today in dentistry it is no longer uncommon to have a device for computer anesthesia, which allows painless administration of medicine and clearly measuring its correct dosage.
Modern anesthesia in dentistry: contraindications for use
The main contraindication to anesthesia in dentistry is an allergy to its components; side effects should also be taken into account, which are most often associated with the presence of additional substances in the anesthetic solution: vasoconstrictors, preservatives and stabilizers. In particular, it is necessary to especially carefully select drugs for patients with cardiovascular diseases, arterial hypertension, and decompensated forms of endocrine diseases (diabetes mellitus, thyrotoxicosis, and others). To determine which substances a person has a negative reaction to, the doctor sends him to the Institute of Allergology to perform tests. In accordance with these data, a safe drug for local anesthesia is selected, and in case of reaction to all groups of anesthetics, general anesthesia is used.
If you are planning a visit to the doctor, we advise you to observe a number of points:
- do not drink alcohol the day before, this may worsen the effect of the anesthetic;
- if you have a cold, cough, or runny nose, it is better to postpone your visit until you have fully recovered;
- Women and girls are not recommended to visit the dentist during menstruation, because... during this period, blood clotting worsens (by the way, do not be surprised if the anesthesiologist asks you this question before surgery; operations are not performed during menstruation.
- choose your clinic carefully! Now their choice is very large, but very few comply with important requirements and all antiseptic requirements!
What are the features of anesthesia in dentistry for pregnant women?
It is also important for pregnant women to ensure pain-free dental treatment. However, conventional painkillers are not suitable for them, since vasoconstrictors (also known as vasoconstrictors) are usually added to the anesthetic solution in order to keep it in the right place and prolong its effect. Vasoconstrictors also reduce potential common side effects and reduce bleeding. For example, adrenaline added to a four percent solution of articaine can extend its analgesic effect from three to forty-five minutes.
Only mepivacaine can be used without adrenaline, since, unlike other drugs for local anesthesia used in dentistry (articaine, which is considered the best option today, novocaine and lidocaine), it does not have the ability to dilate blood vessels at the injection site, which means it can be recommended for pregnant women, children, and other categories of patients who should not be administered adrenaline. These include, for example, those suffering from cardiovascular diseases, arterial hypertension, severe forms of diabetes mellitus, and severe thyrotoxicosis.
