Indications for local anesthesia in dentistry. Anesthesia in dentistry side effects. Modern anesthetics for pain relief in dentistry - advantages and disadvantages of drugs for local anesthesia

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MODERN METHODS OF LOCAL ANESTHESIA IN DENTISTRY

Department of Propaedeutics of Dental Diseases

Department of Surgical Dentistry

T.D. Fedosenko, A.P. Grigoryants,M.M. Soloviev.

Introduction

Painless dental procedurescentury was only a dream of mankind. Discovery of local anestheticsproperties of cocaine, the synthesis of adrenaline and other drugs led to the developmentke different methods of anesthesia, indications for their use and definitioncontraindications. Over the past years, local anesthetics of the fifth generation have appeared, and the exactingness of patients for painless and comfortable various kinds dental activitiescontinues to grow.

In this regard, the purpose of these guidelines is todeepening and expanding students' knowledgeIII, IVandVcourses about local anestetics of the latest generation, modern techniques local anesthesia and prevention of complications in their use.

Local anesthesia or local anesthesia is such methods of influencing the tissues of a certain area of ​​the human body, in which you do notconsciousness turns on and there is a loss of pain sensitivity of tissuesthis area. Modern methods local anesthesia in dentistry include the use of fifth-generation anesthetics (articaine series), the carpool system, and the rational use of various anesthesia techniques.

CLASSIFICATION OF LOCAL ANESTHESIA METHODS

Non-injection methods:

physical (use of low temperatures, laser beams, electromagnetic waves);

physical and chemical (administration of anesthetics by means of electrophoresis);

chemical ( application anesthesia).

Injection methods:

infiltration anesthesia (soft tissues, subperiosteal, intraligamentary, intraseptal, intrapulpal);

conduction anesthesia (extraoral, intraoral).

Non-injection methods

The use of non-injection anesthesia methods in modern dental practice is very limited. The use of liquids with a low boiling point (chloroethyl, pharmacoethyl) leads to a rapid cooling of the tissues, in which the nerve endings lose their sensitivity and it becomes possible to drain subcutaneous or submucosal abscesses, remove moving teeth. Anesthesia comes on immediately, but passes quickly. The disadvantages of this method include the danger of getting the drug into Airways patient and doctor, the likelihood of tissue burns and the development of a toxic reaction. The introduction of an anesthetic by electrophoresis leads to anesthesia of soft tissues to a depth of about 5 mm. This technique was previously used in the treatment of neuralgia trigeminal nerve and during free skin grafting. The main indication for the use of topical anesthesia is to ensure painless injection of the needle, especially in children and patients with a labile psyche.

Preparations for application anesthesia:

Decain 0.25%, 0.5%, 1% and 2% solutions

Perylene-ultra "Septodont"- 3.5% dicaine solution

with antiseptic

Railing spray

Pyromecaine 1 -2% solution; 2-5% ointment with methyluracil

Lidocaine 2.5-5% ointment; 10% spray, Xylonor, Xylonor gel

injection methods

Drugs used for injectable methods include local anesthetics and vasoconstrictors.

Classification of local anesthetics:

esters(in terms of strength - weak):

anestezin (anestalgin), dikain (tetracaine), novocaine (procaine).

amides

- by strength of action - medium:

lidocaine (xycaine, xylocaine, lignospan, xylonor), trimecaine

(mesocaine), mepivacaine (carbocaine, mepivastezin, scandonest, scandicaine), prilocaine (xylonest);

- by strength of action - strong:

articaine (ultracaine, septonest, alfacaine, brilocaine, ubistezin), bupivacaine (marcaine, duracaine, carbostesin), etidocaine

To enhance the action of local anesthetics, the duration of their action and reduce the amount of injected solution in dentistry, vasoconstrictors: epinephrine, epinephrine, supranephrine (4 times stronger than norepinephrine), norepinephrine, vasopressin.

In the presence of a vasoconstrictor in the composition of local anesthetic preparations, preservatives (parahydroxybenzoates) and stabilizers (sodium and potassium sulfites) are used to increase the shelf life. Stabilizers (antioxidants) protect catecholamines from oxidation, but can cause allergic reactions in patients with hypersensitivity to sulfites.

Considering the possibility of developing adverse reactions, in patients with mild comorbidities, vasoconstrictors are used after premedication and in minimal concentrations (1:200,000).

Indications for the use of vasoconstrictors:

at surgical interventions: outpatient surgeries, atypical tooth extraction, pain relief for inflammatory processes(periostitis, osteomyelitis);

when preparing hard dental tissues, depulping.

Contraindications to the use of vasoconstrictors:

in patients with arterial hypertension, with heart defects, to patients with CVD, especially if they were the result of rheumatism;

patients with severe form of diabetes mellitus in the stage of decompensation;

patients who are being treated with tricyclic antidepressants (amitriptyline);

patients who are about to undergo doping control;

patients with thyrotoxicosis;

pregnant women;

patients with angle-closure glaucoma.

Fear of dentists is so common that this phobia has several names at once: stomatophobia, odontophobia, and dentophobia. Most of the procedures that dentists perform are really uncomfortable. This is not surprising, the sensitivity of the tissues of the oral cavity is on average six times higher than the sensitivity of the skin. That is why trips to this specialist rarely do without anesthesia.

To prick or not to prick?

There are two types of anesthesia: general and local. Most often, dentists prefer the latter.

“General anesthesia is essentially anesthesia. Dentists mainly work with local anesthesia, that is, they only anesthetize a certain area, ”said manager dental department one of the private clinics in Moscow Anna Gudkova.

There are several types of local anesthesia: application, infiltration, conduction, mandibular, torusal and stem. At the same time, the application the only way anesthesia that does not require the use of a needle.

“With application anesthesia, a gel or ointment is applied directly to the mucous membrane and only freezes it,” the expert noted, adding that this method of anesthesia is suitable, for example, for removing tartar.

Other types of anesthesia differ only in the technique of administration.

“They differ only in the technique of insertion. For example, experts know that conduction anesthesia cannot be done on the upper row of teeth, the injection is made precisely in the corner mandible", - explained Gudkova.

To reduce pain, dentists give an injection using special carpool syringes, which have a thinner needle. In addition, the device is designed in such a way that foreign substances do not get into the anesthetic.

Replacement for cocaine

The safety of anesthesia largely depends on which drug the doctor chooses. Local anesthetics are divided into amide and ether. One of the oldest painkillers is novocaine. It was first synthesized back in 1898 by the German chemist Alfred Einhorn and replaced the cocaine used for local anesthesia at that time.

“Today, novocaine as an anesthetic drug is used extremely rarely. He has a very large latency period, that is, it acts after 10, 15, or even 20 minutes. Now there is too little time for a patient’s appointment, so there is no way to wait 20 minutes for the anesthesia to take effect,” the candidate said. medical sciences, Associate Professor of the Department of Anesthesia in Dentistry, Moscow State University of Medicine and Dentistry (MGMSU) Elena Zoryan.

According to the specialist, novocaine is usually contained in ampoules, which means that it is almost impossible to maintain the sterility of the anesthetic. The drug also has other disadvantages.

"Novocaine dilates blood vessels, so earlier anesthesia was very weak and did not last long. Adrenaline was added to increase the duration of action. However, to confirm the accuracy of the dosage in this case was, of course, impossible,” explained the dentist with 50 years of experience.

Amide instead of ether

Modern doctors prefer to use drugs of the amide group. According to the expert, they act faster and the effect lasts longer. Most often, dentists use lidocaine, articaine and mepivacaine for pain relief. Each of these drugs has its own advantages and disadvantages, the doctor noted.

"AT public clinics Lidocaine is mainly used because it is cheaper. This is the first drug from the group of amides, which was put into practice. It begins to act within 2-5 minutes after application. And this is the only drug that gives all types of pain relief. That is, it can not only be injected inside, but also applied to the mucous membrane, ”Zoryan said.

However, like novocaine, lidocaine comes in ampoules and is sold in various concentrations.

“Dentists can only use it at a 2% concentration, but there are ampoules of 10% concentration of lidocaine,” the doctor explained.

In addition, the drug penetrates into tissues and is rapidly absorbed into the blood, which can adversely affect patients with impaired functioning of the cardiac and nervous system.

“Lidocaine, like other local anesthetics, dilates blood vessels, so it should be used in conjunction with drugs that narrow them - vasoconstrictors. Therefore, for injection, the doctor can only use a 2% solution. Higher concentrations are sometimes used for surface anesthesia. However, in this case, it is also important to remove excess anesthetic, ”the expert warned.

Lidocaine should not be used by people with severe violations work of the liver and kidneys, as well as use with caution during pregnancy, lactation and in diseases of the hematopoietic organs.

Choosing a dentist

According to the candidate of medical sciences Zoryan, doctors use articaine much more often. It is also known as ultracaine.

“It breaks down faster, is more quickly excreted from the body. In addition, it is less absorbed into the blood and almost does not pass into breast milk. That is, contraindications for use are much less. The drug is used only for injection species local anesthesia", the expert said.

It is also often used in conjunction with vasoconstrictors. According to the dentist, because of the latter, a person can have an increased heart rate and blood pressure.

“Already this should alert the doctor when he deals with patients with cardiovascular insufficiency' the doctor warned.

Negatively, vasoconstrictors, which are essentially adrenaline, can affect people with severe pathology thyroid gland, hypersensitivity to adrenaline, as well as in patients with open-angle glaucoma.

“That is, an anesthetic containing a vasoconstrictor has a number of contraindications. In addition, these drugs are not combined with all drugs and can provoke allergic reactions, especially in patients with hypersensitivity to sulfur. These, for example, include people with bronchial asthma,” the dentist warned.

If a person does not tolerate an anesthetic with a vasoconstrictor, doctors use mepivacaine.

The main thing is not to be silent

It is worth noting that before proceeding directly to the procedure, the dentist should ask the person what he is allergic to, whether there is an intolerance to drugs and whether there were any diseases. of cardio-vascular system. To choose the right anesthetic, it is also important for a specialist to know the condition of the patient's liver and kidneys.

“In case of an allergy to medications, we refer the patient to allergic tests. The results of such a test are usually ready in three days. In some clinics, the analysis is ready within a day,” said Anna Gudkova.

However, according to her, most often people feel bad during a visit to the dentist not because of the anesthetic, but because many patients are afraid of the upcoming procedure or do not have time to eat before the appointment.

The success of the procedure depends not only on the doctor, but also on the patient himself, Elena Zoryan is sure. The candidate of medical sciences advises to approach the dentist responsibly and always inform the specialist about your diseases and allergies in advance.

“The patient must necessarily inform the doctor about the presence of complications from the cardiovascular system, gastrointestinal tract and immune system. In addition, it is worth mentioning allergic reactions for drugs and food. Because very often in food products sulfites are used as an antioxidant, which are also added to local anesthetics, ”the doctor warned.

There are 3 main criteria for the quality of anesthesia: 1) efficiency; 2) security; 3) simplicity and minimal pain of execution.

There are six methods of anesthesia in dentistry:

1. Application
2. infiltration
3. Conductor
4. Intraligamentary
5. Intrapulpal
6. Intraosseous

Conduction anesthesia provides the deepest anesthesia (but it is not always possible to achieve it on the first try). From a safety point of view, this method gives the most complications.

The safest and most painless topical anesthesia (no injection). But it is also the most inefficient. At the same time, the sensitivity of the teeth is not turned off at all, only the mucous membrane is anesthetized.

In terms of benefit and ease of implementation / potential harm, it is preferable infiltration anesthesia. For most dental procedures, it is quite enough, but the lower chewing teeth in this way they are anesthetized with difficulty.

Intraligamentary, intrapulpal and intraosseous techniques are highly effective, but very painful. They are performed after preliminary infiltration or conduction anesthesia.

Of the drugs, articaine is the most effective. Commercial names: "Ultrakain", "Ubistezin", "Septanest", "Alfakain", etc. From these brands for a long time"Ultrakain" remained the leader - this name is now more popular than "articain". However, with the purchase of the German company Hoechst with the French Sanofi and the opening of the last plant in Russia (Sanofi-Aventis Vostok), the quality of this anesthetic Russian market fell. Today "Ubistezin" is more effective than "Ultracain".

An important role is played by the concentration of adrenaline in the anesthetic solution - the higher it is, the stronger the pain relief. The most effective is 4% articaine in combination with adrenaline in a ratio of 1:100,000. Under the trademark "Ubistezin" a drug is produced with a vasoconstrictor content of 1: 200,000. "Ubistezin forte" contains just a concentration of 1: 100,000 - this is the most effective anesthetic to date.

Mepivacaine without adrenaline is the safest anesthetic available in Russia. But its effectiveness and duration of action are significantly inferior to articaine with adrenaline.

A visit to the dentist causes many people unpleasant associations and reluctance to go to the clinic. In most cases, this is due to previously experienced pain with insufficient quality treatment.

However modern medicine has many ways to neatly and safe anesthesia. Local anesthesia, which is now used in dental clinics, can completely relieve the patient not only of painful, but also discomfort .

What is the procedure?

Doctors call this phrase complete loss sensitivity of tissues to any irritation in a certain area using the injection of certain drugs. That is, it is in the place that will be subjected to medical manipulations that the patient stops feeling anything, while remaining conscious.

Also quite common are the names local anesthesia and local anesthesia. By using specific drugs, which are introduced into the body directly at the desired site, nerve cells there for a while stop conducting impulses.

Classification

On the this stage All local anesthesia in dentistry is divided into two main types - injection and non-injection. Each of them has several separate specific techniques.

Non-injection local anesthesia

All these methods are united by the fact that in order to achieve a result there is no need to make an injection or injection.

1. Application method. Also called chemical. Quite often used to anesthetize the oral mucosa. The drug in this case is applied or simply rubbed into the desired area.
2. Physical. It is used very rarely due to a rather weak, superficial effect. When using this method, the desired tissue area is frozen by spraying. various substances, who have very low temperature boiling. Evaporating quickly, they cool the tissues, thereby blocking the nerve endings.
3. Physico-chemical. An anesthetic is injected into the desired tissue area using electrophoresis. In most cases, this technique is used for neuralgia.

Injectable local anesthesia

The techniques listed here show top scores than pain relief without injections. Besides, the effect of painkillers in this case lasts much longer.

That is why doctors prefer injections for local anesthesia in dentistry.

This type of anesthesia can be divided into four types, depending on the method and specific injection site. It is worth describing each of them in more detail.

Conductor

In this case the medicine must be injected right next to the nerve Thus, the drug covers with its action the tissues surrounding the nerve, and itself. Most often used by dentists when performing complex operations with localization on the lower part oral cavity and lower jaw.

The peculiarity of this type is that the nerve needs to be blocked in soft tissues. It turns out to be "locked", so the impulses from this area do not reach the brain and the patient "does not know" that he is experiencing some sensations.

infiltration

AT this case an injection is made in the area where the projection of the top of the root of the diseased tooth is located. Several injections can be made from different sides.

After that, the drug is gradually distributed through the hole that exists in the plate. alveolar process, after which it reaches the inside of the tooth and acts from the inside.

intraligamentous

It also has a different name - intraligamentary. Injections here are made from the outside and inside into the periodontal ligament through the gingival sulcus. At the same time, numbness of the gums from all sides and the tooth itself occurs instantly.

Quite often, this method is used for pain relief in children. In this case, both the needle itself and the medicine cartridges are used. special size- reduced. This method in adults can be combined with other methods of drug administration.

Intraosseous

The injection is made directly into the bone between two teeth.. This bone has a special structure and is called spongy. So that the injection itself does not cause discomfort or pain, before that, the doctor injects a few drops of an anesthetic directly into the gum.

This method has several features. First, anesthesia lasts quite a short time. Secondly, numbness covers only the teeth and gum surfaces in the desired area.

At the same time, the lips, tongue and cheeks are completely felt by the patient, which is very important for short-term dental operations - there are no inconveniences after their completion.

Another method of injection anesthesia should be described separately, since in most cases it is used in conditions inpatient treatment if the patient has neuralgia or decreased pain threshold i.e. increased sensitivity.

It consists in the fact that with the help of the drug, all branches of the trigeminal nerve are blocked. To do this, an injection should be made at a special point located at the base of the skull.

Instruments and preparations for carrying out

To achieve the desired result from local anesthesia, it is important to choose not only the drug, but also the instruments with which they will be administered.

Tools

The majority of clinics practice carpool anesthesia. For them, the same methods and preparations are used as for other species.

The main difference is that the drug is not enclosed in ampoules, but in separate vials. They are inserted into special syringes-injectors. When dressing the needle, the capsule is pierced and the drug can be injected.

The advantage of this method is complete guaranteed sterility, since the drug capsules are airtight. As well as a more gentle injection of the drug due to the very small thickness of the needle.

In addition, carpules (i.e., capsules) may additionally contain vasoconstrictor drug(most often adrenaline) so that the effect of the anesthetic is longer.

However, conventional syringes with needles are also used in dentistry. For the most part they are disposable, however, can be used and reusable. The effectiveness of these tools is less compared to carpool injectors. This is due to some design and size flaws.

For example, the needle diameter of conventional syringes is about 0.7–0.8 mm. The tissues in the oral cavity are highly saturated blood vessels, and when using such needles, hematomas and other unpleasant complications may occur.

Also, during the procedure for drawing anesthetic from the ampoule, sterility may be violated, which is unacceptable.

Preparations for dental local anesthesia

There are some of the most effective and common drugs that are used in dental practice for local anesthesia.

1. Ultracain. Produced by a French company based on articaine. There are three main forms that differ in the presence and concentration of an additional vasoconstrictor component - epinephrine. The drug is produced with the markings "D", "DS" and "DS Forte". In the first case, epinephrine and preservatives are not added to it.
2. Ubistezin. An analogue of ultracaine, produced in Germany. It has two release forms different concentration components.
3. Septanest. A proven and high-quality anesthetic, but it contains a large concentration of preservatives, so there is Great chance allergic reactions in susceptible patients.
4. Skadonest. Produced by Septodont, France. The drug is based on 3% Mepivacaine. It does not contain preservatives and various vasoconstrictor additives. Suitable for patients at risk.

Indications

By and large, indications for local anesthesia in dental practice are almost any intervention that is usually accompanied by pain. They can be submitted as a list.

• Treatment of caries in a complex form.
• Periodontitis.
• Extraction of one or more teeth, as well as separately the roots.
• Purulent inflammations and similar processes in the bones of the jaws.
• Inflammatory lesions of the jaw joint.
• Neuralgia, neuritis of the facial nerve.
• Impossibility of carrying out complex interventions under general anesthesia.

In addition to this list, exclusively dental indications, can also be called intense fear patient before any manipulation.

Contraindications

It is mandatory to interview the patient before the treatment procedure. The answers are very great importance for the choice of a specific method of anesthesia, as well as certain drugs.

Some diseases, in particular, the patient's previous infection, may be a contraindication to some types of injection anesthesia.

List of contraindications

• Postponed no more than 6 months ago, stroke or heart attack.
• individual allergy.
• thyroid disease, diabetes and other diseases endocrine system suggest the absence of vasoconstrictor components in the anesthetic.
• If the patient has heart disease and high blood pressure, then it is highly undesirable to use drugs in which the concentration of epinephrine is higher than 1: 200,000.
• Increased allergies or the presence of bronchial asthma require the absence of a preservative in the preparation. Most often it is sodium disulfide.

During pregnancy

The bulk of the drugs used for local anesthesia in dentistry cannot overcome the placental barrier. It means that they do not enter the body of the child and are safe for him.

That is why, both during pregnancy and during breastfeeding, anesthesia can be done.

During pregnancy, excessive pain for the mother can harm the baby much more than drugs that are used to get rid of pain. However, the choice of a particular drug is still important, because it is not worth exposing the child to danger (even hypothetical) once again.

The only period when the use of such drugs is undesirable is the first trimester of pregnancy.

The safest for women in the "position" are Ultracaine DS, as well as Ubistezin. In both of these drugs, the concentration of epinephrine is 1 in 200,000.

Pain relief - obligatory part sets dental procedures, which imply possible pain sensations. Today, dentistry is a painless and fast treatment.

In conclusion, a video in which a dentist of one of the clinics talks about local anesthesia:

If you find an error, please highlight a piece of text and click Ctrl+Enter.

From this article you will learn:

• anesthesia in dentistry - drugs,
• the best anesthesia for dental treatment,
• dental anesthesia during pregnancy breastfeeding.

The article was written by a dental surgeon with more than 19 years of experience.

Anesthesia in dentistry can be local or general. Local anesthesia is when only the area where the intervention is planned is anesthetized, while the patient is conscious (Fig. 1-2). But general anesthesia in dentistry or in other words - is carried out with the help of narcotic analgesics, introduced into the patient's body by inhalation (Fig. 3) or intravenously. At general anesthesia the patient is unconscious.

Local anesthesia during tooth extraction, dental treatment -

For local anesthesia, carpool syringes and carpules are now used, in which the anesthetic solution is enclosed (Fig. 4-5). The quality of anesthesia with such a syringe is much higher than with a conventional disposable syringe. In addition, needles for carpool anesthesia are many times thinner than conventional disposable syringes (Fig. 6), which means that the injection will not be as painful.

The cost of anesthetics and anesthesia –
the cost of one cartridge of anesthetic (whether ultracain, ubistezin, septanest or others) is about 30 rubles. Cost per anesthesia dental clinic will average 250 rubles.

What to do if you are afraid of anesthesia -

Indeed, an anesthetic injection can be painful. Soreness will depend both on the threshold pain sensitivity the patient himself, and on the technique of anesthesia by the doctor. According to the rules, one anesthetic cartridge (1.7 ml) must be injected within 40-45 seconds. If the doctor saves time and injects the anesthetic quickly, then it is logical that this will cause pain.

2. Ubistezin - instructions for use

3. Septanest - instructions for use

4. Scandonest - instructions for use

Which anesthetic is right for you: summary

• If you have bronchial asthma or very allergic –
  here you need an anesthetic without preservatives (usually sodium disulfite is used in anesthetics, which is needed to stabilize epinephrine or adrenaline). Therefore, the anesthetic "Ultracain D", which does not contain preservatives at all, is best for such patients.

• If you have thyroid disease, diabetes –
  in this case, it is also undesirable for you to use anesthetics containing vasoconstrictor components - adrenaline, epinephrine. The drug of choice, for example, "Ultracain D", "Scandonest" or "Mepivastezin". But, choosing between these three anesthetics, I would prefer the first.

• If you have high blood pressure and heart disease –
  with moderate hypertension and compensated heart diseases, the optimal choice is anesthetics containing a concentration of epinephrine (adrenaline) - 1: 200,000. It can be anesthetics "Ultracain DS" or "Ubistezin 1: 200000".

  In severe hypertension, decompensated heart disease, it is necessary to use anesthetics that do not contain adrenaline and epinephrine. Suitable then, for example, "Ultracain D".

• If you healthy man –
  if you do not have the above diseases, then you can safely put anesthetics containing epinephrine / adrenaline at a concentration of 1: 100,000. Moreover, a person weighing about 70 kg can be given up to seven cartridges of anesthetic, inclusive. An example of such anesthetics is "Ultracain DS forte", "Ubistezin forte" and analogues.

Anesthesia in dentistry during pregnancy and breastfeeding -

Best Choice for dental interventions during pregnancy, as well as during breastfeeding - is "Ultracain DS" (with an epinephrine content of 1: 200,000), or "Ubistezin 1: 200,000". Ubistezin during pregnancy is as safe as ultracain. The 1:200,000 concentration of epinephrine that is present in these anesthetics does not affect the fetus, does not cross the placenta, and is not detected in breast milk.

It is impossible to completely abandon the content of adrenaline in anesthetic in pregnant and lactating patients, because. epinephrine constricts the blood vessels in the injection area and therefore slows down the absorption of the anesthetic itself into the blood, and this in turn leads to a marked decrease in the concentration of the anesthetic in the blood. But the higher the concentration of the anesthetic in the blood, the greater the chance of the anesthetic to penetrate the placenta.

Some doctors use anesthetics Scandonest or Mepivastezin for pain relief in pregnant women (they do not contain either adrenaline or epinephrine). However, as you already understood, it is undesirable to use such anesthetics in pregnant and lactating women, because. due to the lack of a vasoconstrictor component, they are absorbed into the blood very quickly, which means that there will be high concentration anesthetic, which will allow the drug to cross the placenta. In addition, both Scandonest and Mepivastezin are 2 times more toxic than novocaine.

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