Local Anesthesia

Andrew G. Drollinger, DDS

Assistant Professor
Roseman University
College of Dental Medicine

Outcomes
Define local anesthesia
Identify chemical configuration and characteristics of
local anesthetics
Identify the desirable properties of a local anesthetic
Describe methods to induce anesthesia
Understand the anatomy of a nerve and nerve cell
membrane
Understand the process of anesthetic diffusion and
electrophysiology of nerve conduction
Describe saltatory conduction and understand its
importance in nerve conduction
Understand the mechanism of local anesthetics

Lecture Outcomes
Understand dissociation of LAs and tissue pH
Understand how low tissue pH (infection) alters
dissociation of LAs
Understand rate of onset and dissociation constants
Describe the factors that affect LA action
Understand the sites of metabolism of LAs
Understand the role and action of vasoconstrictors in LAs
Understand the systemic effects and drug interactions of
vasoconstrictors
Define methemoglobinemia
Understand the maximum dosages of LAs for children and
adults

Lecture Outcomes
Calculate amount of LA and
vasoconstrictor found in a dental
anesthetic cartridge
Understand anesthetic delivery
equipment
Describe medications used in post op
pain management

ANESTHESIA
An----------without
Esthesia---ability to experience sensation
Handbook of Local Anesthesia 6 th edition
By Stanley F. Malamed
Reading assignments:
Part 1 (chapters 1-4)
Chapter 16
Chapter 21 Questions
(local anesthetics & vasoconstrictors)

WHAT IS LOCAL
ANESTHESIA?
Loss of sensation in circumscribed
areas of the body without loss of
consciousness caused by depression of
excitation in nerve endings
- This is a physiologic process -

METHODS TO INDUCE ANESTHESIA?

Mechanical trauma (compression of tissues)

Sensory nerves over-fire producing loss of sensation due to depletion of NTM
(nuclear transport modulation)

Low temperature

Anoxia
deprivation or relative decrease in O2

Chemical irritants
Can cause nerve damage effecting transmission of nerve impulse
Example: Sargenti method of endodontics made pts lips go numb after RCT
Benadryl has weak analgesic properties

Neurolytic agents such as alcohol and phenol

Alcohol & phenol blocks
Risk of developing Anesthesia Dolorosa

Chemical agents such as local anesthetics

DESIRABLE PROPERTIES OF A LOCAL

ANESTHETIC

Non-irritating to the tissues

addition of sodium bicarbonate can make it non-irritating and speed its onset of action

No permanent alteration of nerve

Alcohol will kill part of the nerve structure
Formaldehyde, Sargenti, and alcohol will denature the protein in the nerve membrane
We need to be cautious in what we choose to use

Low systemic toxicity

All drugs will disperse throughout the body and there will ALWAYS be a systemic consequence
Bupivicaine (Marcaine) avoid use in pediatrics due to prolonged anesthesia
http://www.aapd.org/media/Policies_Guidelines/G_LocalAnesthesia.pdf

Effective as a topical and injectable

Short onset of action & appropriate duration of action

Lidocaine is a good LA for dentistry, lasts about 30 min (longer with epinephrine)
Bupivicaine has the longest duration of action, 6-8 hours

-Quick side note about

anesthesiaApplicable information and vital to
your success!

ANATOMY OF A NERVE
The neuron is the basic structural unit
of the nervous system
Two types of neurons - functionally
Sensory afferent
Motor efferent

Two types of neurons morphologically

Bipolar (pseudounipolar)
multipolar

ANATOMY OF A NERVE
The axon typically has a superficial
layer called myelin (Schwann cells)
Cell body of a motor neuron is
involved in transmission (nodes of
Ranvier, speed of transmission)
Cell body of a sensory
Neuron is only available
For nutritional support

 Myelin:
Lipioproteinaceous substance (specialized
Schwann cells)
Increases the speed of transmission
Acts as a barrier to LA

Site of action for LA

Nodes of Ranvierevery 0.3-0.5 mm, but can be
up to 2 mm
Profound anesthesia when 2-3 adjacent Nodes of
Ranvier are bathed in LA and/or a minimum of 810 mm

SALTATORY PROPOGATION

The message
leaps from one
Node of Ranvier to
the next
https://www.youtu
be.com/watch?v=A0
Z78rFPFCA

Inferior alveolar nerve

 Axons in a bundle are called fasciculi and

covered in endoneurium
Innermost layer of the perineurium is called
the perilemma which is the main barrier to
diffusion of LA

Cell Membranes (nerve membrane)

Whats the general makeup of a cell
membrane?
Phospholipid bilayer

Cell/nerve membrane
Blocks diffusion of water soluble
molecules
Semi-permeable to certain molecules
via channels or pores
Transduce information from the
extracellular surroundings (matrix)
intracellularly via proteins
embedded in the membrane

 What can interact with these proteins

embedded in the membrane?
1. Neurotransmitters (i.e. hormones,
chemicals)
2. Pressure
3. Light
4. Vibration

Proteins
What are the two main types of
membrane proteins?
1. Transport proteins (channels,
carriers or pumps)
2. Receptor proteins

Transport proteins
Continuous channels
passive flow of ions (Na, K, Ca)

Gated channels
Gate must be open to allow passage

Drum Roll Please!

The passage of ions through these
gates allow a nerve impulse!!!

Myelinated nerve fibers

What is myelin?
Insulating lipid layer

What actually forms the myelin?

Schwann cells

Unmyelinated nerve fibers

Actually surrounded by a schwann
cell sheath or myelin
Caveat
Multiple nerve fibers share the same
sheath

Why is this important to

know?

The insulating properties of the

myelin make nerve conduction much
faster than the unmyelinated fibers

Saltatory conduction
saltare= to leap

So
During an injection which nerves lose sensation first?
A. Small unmyelinated nerves or
B. Large myelinated nerves

Why?
Smaller diameter means less stuff to go through

Myelin
Myelin insulates the axon both electrically and pharmacologically
Na+ channels found mainly at nodes of Ranvier
An electrical impulse can jump over 1-2 nodes of Ranvier
2-3 successive nodes need to be blocked to halt propagation
The more myelinthe further apart the nodes, hence the harder to block

Anesthetic Diffusion
LA becomes increasingly
diluted by tissue fluids and
removed by capillaries and
lymphatics
Core fibers are exposed to a decreased concentration
of LAmore difficult to achieve profound anesthesia
distal distribution
Mantle fibers (surface) are exposed to higher
concentration LA easier to achieve profound
anesthesiaproximal distribution
Profound anesthesia can be more difficult for premolars
than molars.

Electrophysiology of Nerve
Conduction

Stimulus applied

Slow depolarization. The

interior becomes less
negative
At a critical level (threshold
level) the depolarization
increases

This rapid depolarization

causes a change in the
polarity across the
membrane. Interior now
more positive.

Repolarization back to the

-70mV

ions
Which cation is predominately found
intracellularly?
K+remains in axoplasm d/t electrostatic
attraction

Which ions are found predominately

extracellularly?
Na+travels inward d/t concentration
gradient and electrostatic attraction
Cl-stays outside d/t electrostatic attraction

Resting potential of the

nerve
What is the resting potential?
A negative electrical potential of -70mV across the
membrane

What produces this potential?

The differing concentrations of ions on either side of
the membrane

Which is negative, the exterior of the nerve or

the interior?
Interior

Transmission of Neuronal
Information
Membrane channelsfound in all
neurons
Nongated
Modality gated (sensory neuron, CN V)
Ligand gated
Voltage gated (voltage-dependent Na+
channels)

Na+ channel
NA+

Nerve at rest
Na+ is about half the size of K+ and
Cl What (primarily) keeps Na+ in the
extracellular space?
H2O
When Na+ becomes hydrated it cannot pass
through its channel, whereas K+ and Cl- can

Nerve at Rest (resting membrane)

channel closed

Hydrated
Na+

Activated nerve (depolarization)

channel open

Hydrated
Na+

Stimulus applied

Slow depolarization. The

interior becomes less
negative
At a critical level (threshold
level) the depolarization
increases

This rapid depolarization

causes a change in the
polarity across the
membrane. Interior now
more positive.

Repolarization back to the

-70mV

Saltatory conduction

Sohow do local anesthetics work?

Block the transmission of the action
potential by inhibition of voltagegated Na+ channels
Na+ channel blockers

Decreasing the rate of depolarization

 LAs do not alter the resting

membrane potentialMiller, Basics of
Anesthesia, 6th edition
Malamed, Handbook of Local Anesthesia, 6th
edition

LAs have very little effect on the

threshold potential

Whats Important
Primary effect of local anesthetics is
to decrease the rate of depolarization
Basicallythey block the depolarization
phase

Remember Na+ influx

Specific Receptor Theory

local anesthetics (and venoms) act
by binding to specific receptors in the
sodium channel

Sodium channel

Note local anesthetic blocks

from the axoplasm side