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Local Anesthesia inDentistry
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Local Anesthesia in Dentistry
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A Locoregional Approach
Jesús Calatayud, MD, PhD, DMD
Associate Professor (retired)
Pediatric Dentistry
School of Dentistry
Universidad Complutense. Madrid (Spain)
Mana Saraghi, DMD, DADBA
President, American Dental Board of Anesthesiology
Director, Dental Anesthesiology Residency Program, Jacobi Medical Center
Assistant Professor of Dentistry, Albert Einstein College of Medicine
Bronx, NewYork (United States)
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This edition first published 2024
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© 2024John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material
from this title is available at http://www.wiley.com/go/permissions.
The right of Jesús Calatayud and Mana Saraghi to be identified as the authors of the editorial material in this work has been asserted in
accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners.
John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and
should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient.
In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating
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or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and
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including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or
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Library of Congress Cataloging- in- Publication Data
Names: Calatayud, Jesús, author. | Saraghi, Mana, author.
Title: Local anesthesia in dentistry: a locoregional approach / Jesús
Calatayud, Mana Saraghi.
Description: Hoboken, NJ: Wiley-Blackwell, 2023. | Includes
bibliographical references and index.
Identifiers: LCCN 2023007820 (print) | LCCN 2023007821 (ebook) | ISBN
9781394180158 (cloth) | ISBN 9781394180165 (adobe pdf) | ISBN
9781394180172 (epub)
Subjects: MESH: Anesthesia, Dental-methods | Anesthesia, Local-methods |
Anesthesia, Dental-adverse effects | Anesthesia, Local-adverse effects
| Anesthetics, Local
Classification: LCC RK510 (print) | LCC RK510 (ebook) | NLM WO 460 | DDC
617.9/676–dc23/eng/20230420
LC record available at https://lccn.loc.gov/2023007820
LC ebook record available at https://lccn.loc.gov/2023007821
on- demand. Some content that appears in standard print versions
Cover Design: Wiley
Cover Image: © Christine von Diepenbroek/Getty Images
Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India
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Contents
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Preface xxiii
About the Companion Website
v
xxv
1 History
2 AppliedAnatomyI:MaxillaryArch 17
ofLocalAnesthesiainDentistry 1
The Coca Leaf 1
Cocaine
The Development ofthe Syringe
The Dangers ofCocaine
Adrenaline andthe Vasoconstrictive Effect
Novocaine or Procaine
The Development ofLocal Anesthesia inDentistry
References
AppliedAnatomy
Introduction 17
Maxillary Nerve (V
Other Structures ofInterest 24
2
3
4
5
Local Anesthetics
Vasoconstrictors
Instruments
Anesthetic Techniques
Twenty-First Century Developments
Frequency ofUse ofLocal Anesthesia inDentistry
9
5
6
7
7
8
15
) 17
2
19
17
17
The Trigeminal Nerve
Trigeminal Ganglion
Trigeminal Nerve: Functions 17
Overview ofCollateral Branches 18
Intracranial Zone 18
Pterygopalatine Fossa Zone 18
Infraorbital Zone 19
Palatine Nerves
Greater Palatine Nerve 20
Nasopalatine Nerve 20
Superior Alveolar Nerves 22
Posterior Superior Alveolar Nerve (PSAN) 22
Middle Superior Alveolar Nerve (MSAN) 22
Anterior Superior Alveolar Nerve (ASAN) 23
Superior Dental Plexus 23
4
5
9
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Contents
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vi
Greater Palatine Canal andForamen 24
Greater Palatine Canal
Greater Palatine Foramen
24
24
Nasopalatine Canal andForamen
Nasopalatine Canal
Nasopalatine Foramen
Cortical Bone Thickness
Pterygoid Venous Plexus
Infraorbital Foramen
Pterygopalatine Fossa
Margins
Content
Glossary
References
26
27
27
28
24
24
25
25
25
26
3 AppliedAnatomyII:MandibularArch 31
31
32
33
33
34
35
36
) 31
3
36
36
33
34
36
Mandibular Nerve (V
Overview
31
Buccal Nerve
Course
32
Innervation
Auriculotemporal Nerve
33
Course
Innervation
Lingual Nerve
33
Course
Innervation
Remarks
34
Inferior Alveolar Nerve
34
Course
Innervation
Remarks
35
Mylohyoid Nerve
36
Course
Innervation
Body ofthe Mandible
Cortical Bone Thickness
Retromolar Zone (Trigone andFossa) 37
Retromolar Trigone 37
Retromolar Fossa 37
Mandibular Canal 37
Mental Foramen 38
Ramus ofthe Mandible 39
Divergent Angle 39
Ramus Width
39
Lingula 39
Mandibular Foramen 39
Sulcus colli 40
Coronoid Notch 41
Accessory Foramina 41
Pterygomandibular Space 41
Anatomic Boundaries ofthe Pterygomandibular Space 42
Open/Closed Mouth and Pterygomandibular Space 44
24
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Contents ofthe Pterygomandibular Space 44
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Sphenomandibular Ligament
Positive Aspirations andHematomas
Glossary
References
4 ThePeripheralNerveandLocalAnesthesia 50
Peripheral Nerve Microanatomy 50
Basic Membrane Proteins
Peripheral Nerve Neurophysiology
Mechanisms ofLocal Anesthesia
Nerve Block Kinetics
References 62
46
46
Neurons
Sensory Neurons
Axons
Membranes
Nerve Fibers andMyelin
Peripheral Nerve Structure
Sodium–Potassium Pump
Sodium Channels
Potassium Channels
Fundamentals
Membrane Potentials: Membrane at Rest (Polarized)
Action Potentials: Excited Membrane
Propagation ofthe Action Potential
Mechanism
Differential Nerve Block
Tonic andPhase Block
Critical Length
Transient Receptor Potential Channel
Induction Stage 60
Recovery Stage 60
Re-Injection 61
Tachyphylaxis 61
Resistance toLocal Anesthetics 61
50
50
50
51
Myelinated Fibers
Unmyelinated Fibers
Nerve Fiber Classification
Phase 1: Depolarization
Phase 2: Repolarization
Phase 3: Hyperpolarization
58
51
52
54
54
55
56
59
59
60
44
45
51
52
52
54
56
56
57
57
57
58
58
58
60
Contents vii
56
Pharmacology
5 Local
Anesthetics 67
Chemical Structure 67
Physical-chemical Characteristics ofLocal Anesthetics 67
Dissociation Constant or pKa 68
Partition Coefficient or Lipid Solubility 69
Protein Binding 70
Vasodilation 70
65
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Contents
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viii
Assessment ofAnesthesia andthe Anesthetic Parameter 70
Assessment ofLocal Anesthesia inDentistry
Anesthetic Parameter
Anesthetic Concentration
Concentration andVolume
Concentration andSafety
Concentration andAnesthetic Potency
Concentration andTissue Irritation
Maximum Doses
Maximum Doses forChildren
Pregnancy andLactation
Pregnancy
Lactation
Mixing Local Anesthetics
Isomers
78
References
6 Vasoconstrictors 85
Introduction 85
Advantages
Disadvantages
Dilutions andConcentrations
Catecholamines
Isomers andCatecholamines
Adrenergic Receptors
Systemic Effects
Heart
Circulatory System
Respiratory Tract
Endocrine System andMetabolism
Uterus
Vasoconstrictive Effect
Catecholamine Metabolism
Epinephrine
Norepinephrine
Levonordefrin
Phentolamine (OraVerse®) 95
OraVerse® 96
Advantages andIndications 96
Technique andDose 96
Clinical Efficacy 97
Tolerance, Toxicity, andAdverse Side Effects 97
Felypressin (Octapressin®)
Cardiovascular Effects 98
Vasoconstrictive Effect 99
Adverse Effects 100
Contraindications 100
Advantages andDisadvantages 100
Maximum Doses 100
Combinations ofVasoconstrictors 101
References 101
70
72
72
72
73
73
73
74
75
76
76
77
77
79
85
85
87
87
88
88
90
90
91
91
91
91
91
92
92
93
94
98
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7 InjectableAnestheticSolutionsUsedinDentistry 107
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Solution Composition 107
Local Anesthetic
Vasoconstrictor
Antioxidants (Sulfites)
Preservatives (Methylparaben)
pH Adjustment
Other Compounds
Procaine (Novocaine)
Metabolism
Procaine withEpinephrine
Remarks
109
Lidocaine (Lignocaine)
Metabolism
Remarks
111
Indications
Standard 2% Lidocaine: L-100with 1:100
Epinephrine
L-50, 2% Lidocaine with 1:50
Articaine
113
Metabolism
Remarks
115
Maximum Dose andToxicity
Anesthetic Potency
Anesthetic Effect
Indications
A-100, 4% Articaine with1:100
A-200, 4% Articaine with1:200
Mepivacaine
Metabolism
Remarks
119
Maximum Doses
Mepivacaine Solutions
Indications
Prilocaine (Propitocaine)
Metabolism
107
107
107
108
108
109
109
109
109
109
111
111
000 (10 μg/ml) Epinephrine or L-80with 1:80 000 (12.5 μg/ml)
111
000 (20 μg/ml) Epinephrine 113
115
115
115
116
116
000 (10 μg/ml) Epinephrine 116
000 (5 μg/ml) Epinephrine 117
117
117
119
119
119
120
120
Remarks 120
Toxicity andSafety 120
Clinical Efficacy 122
Prilocaine Solutions 122
Indications andContraindications 122
Indications 122
Contraindications
123
Bupivacaine 123
Metabolism 123
Remarks 123
Indications andContraindications 125
Indications 126
Contraindications 126
References 126
Contents ix
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