oral surgery

1. by: Dr.
Mohammad Hassan Nour

2. 1. It should be non irritating to tissues.
2. It should not cause permanent nerve structure
alteration.
3. It should have low systemic toxicity.
4. It must have sufficient potency.
5. It should have sufficient penetrating properties.
6. It should have rapid onset.
7. It should have long duration of action.
8. It should be non allergic.
9. It should be sterile.
10. It should be stable in solution and undergo
biotransformation readily within the body.

3. 1. Anesthetic drugs
2. Vasoconstrictor (optional)
3. Preservative
4. Vehicle
5. Distilled water

4. Uptake
Distribution
Metabolism
Excretion

5. Uptake
Route of administration …. ???
Vasodilatation except ???

6. Distribution
Higher blood levels in………???

7. Metabolism
Esters plasma by .......... ???
Amides liver by ………. ???
Why ???

8. Excretion
 By kidneys for both groups.
 Clinical significance ….... ???

9. 1. Esters:
 Tetracaine
 Procaine
 Cocaine
 butacaine
2. Amides:
 Lidocaine
 Mepivicaine
 Articaine
 prilocaine

10. Lidocaine
potency: 2 (compared to procaine = 1)
toxicity: 2 (compared to procaine = 1)
metabolism: liver excretion: kidney
onset of action: 2-3 min
effective conc.: 2 %
anesthetic half life: 90 min
Duration:
without v.c.: pulpal 5-10 min,
soft tissue  60 -120 min
with v.c. adrenaline1: 100000:
pulpal  60 min,
soft tissue  3-5 hr
Maximum dose: 4.4mg/Kg or 300mg

11. Mepevacaine
potency: 2 (compared to
procaine = 1)
toxicity: 2 (compared to
procaine = 1)
metabolism: liver
excretion: kidney (1-16%
unchanged)
onset of action: 1.5-2 min
effective conc.: 3% without
V.C., 2% with V.C.
Maximum dose:
4.4mg/kg or 300mg
Duration:
without v.c.:
pulpal 20-40 min,
soft tissue  2-3 hr
with v.c. adrenaline1:
100000:
pulpal  60-90 min,
soft tissue  3-5 hr
with v.c. levonordefrine1:
200000:
pulpal  45-60 min,
soft tissue  2-4 hr

12. Prilocaine
Potency: 2 (compared to
procaine = 1)
toxicity: 40% less toxic
than lidocaine
metabolism: liver & lung
excretion: kidney
onset of action: 2-4 min
effective conc: 4%
Duration:
without v.c.:
pulpal 10min infilt...,
60 min nerve block,
soft tissue  2-4 hr
with v.c. adrenaline1:
100000:
pulpal  60-90 min,
soft tissue  3-5 hr
Maximum dose:
6 mg/Kg or 400mg

13. Duration:
with v.C. Adrenaline1:
200000:
pulpal  90-180 min
soft tissue  4-9 up
to12 hr
maximum dose:
1-3 mg/kg or 90 mg
Bupivacaine(marcane)
Potency: 4 times of
lidocaine and
prilocaine
Toxicity: < 4 times of
lidocaine
Metabolism: Liver
Excretion: Kidney
Onset of action: 6-10
min
Effective conc: 0.5%

14. Duration:
WITH V.C. ADRENALINE1:
200000:
INFILTRATION  3 HR
BLOCK  4-4.5 HR
WITH V.C. ADRENALINE1:
100000:
INFILTRATION 4 HR
BLOCK  5 HR
Maximum dose:
7 MG/KG OR 500 MG
Articaine
Potency: 1.5 times of
lidocaine
Toxicity: 0.6 times of
lidocaine
0.8 times of
procaine
Metabolism: Liver
Excretion: Kidney
Onset of action: infil. 
1-2 min
block 2-3 min
Effective conc: 4%

15. Procaine
POTENCY: 1
TOXICITY: 1
METABOLISM: PLASMA
EXCRETION: MORE THAN
2%UNCHANGED IN URINE,
90%AS PABA
ONSET OF ACTION: 6-10
MIN
EFFECTIVE CONC: 2-4%
ANESTHETIC HALF LIFE:
1.2 TO2 HR
Duration:
-no pulpal anesthesia and
provides 15- 30min soft
tissue anesthesia
-with v.c. it can provide 60-
90 min soft tissue anesthesia
Maximum dose:
6 mg/Kg or 400 mg

16. 1-The mechanical or reversible coagulation theory.
2-The physiological or interference with tissue
metabolism theory.
3-Acetylcholine and enzyme system theory.
4-Electrical potential theory.
5-The calcium displacement theory.
6-The specific receptor theory.

19. ⇋RNH +
H+
+ RN

20. Nerve membrane
N
A
C
h
a
n
n
e
l
RNH +
H+
RN

22. I – pH of the tissues and pKa of the agent
1. Pka of LA (dissociation constant)
2. pH of LA
3. pH of tissues

23. II – Diffusion to the site:
Shorter distance ⇒ faster onset
III – Concentration:
 Excessive dilution
 Rapid absorption
IV – Nerve size & type

24. 1. pH
2. Lipid sol.
3. Conc.

25. 1. Protein binding
2. Diffusion away from site
3. Conc.
4. Lipid sol.
5. Type of injection

26. Vasoconstrictors are important addition to L.A. for :
1-By constricting blood vessels →decrease blood flow
at the site of injection→ decrease bleeding and
enhance hemostasis.
2-Decrease blood flow → decrease absorption of L.A.
into blood stream and hence, decrease the potential
of overdose reaction and high conc. of L.A. remains
in and around the nerve for a longer period →
increase duration of action.

28.  Malignant hyperthermia:
A genetic variant that alters response to
certain drugs
 S&S:
1. heart rate
2. Cyanosis
3. Fever
4. Muscle rigidity & death

29. Types of vasoconstrictors:
-Adrenaline (Epinephrine)
-Levonordefrine
-Noradrenaline (norepinephrine)
-Phenylephrine
-Felypressin

30. Concentration of vasoconstrictors:
- 1:1000  1 gm of drug in
1000ml→1mg/1ml
-1:20000  0.05mg/ml
-1:50000  0.02mg/ml
-1:100000  0.01mg/ml
-1:200000  0.005mg/ml

31.  It is a potent stimulator of both α and β receptors with a predominance of β2
effect.
 Stimulation of β1 receptor (present in myocardium)→ increased force of
contraction, rate of contraction, heart rate, cardiac output, myocardial O2
consumption and increased risk of dysrhytmias.
 Effect on metabolism:
 Increase O2 consumption of all tissues.
 increased in blood sugar level.
 Max dose: 0.2 mg / appoinment

32. It is a potent stimulator of both α and β receptors
with a little β2 effect → significant rise in blood
pressure and intense vasoconstriction of skin and
mucous membrane → sloughing of oral mucosa.
Stimulation of β1 receptor (present in myocradium)→
increased force of contraction, rate of contraction,
heart rate, cardiac output, myocardial O2 cosumption
and increased risk of dysrhytmias→ absolutely contra-
indicated in cardiac patient.
Effect on metabolism:
Increase O2 cosumption of all tissues.
incraesed in blood sugar level.
 Max dose: 0.34 mg/appoinment

33. Direct alpha and beta receptors stimulant but the
alpha effect is predominant.
It is 15% as potent vasopressor as adrenaline.
It produces less cardiac stimulation than
adrenaline.
 Max dose: 1 mg/appoinment

34.  It is a synthetic analogue of the antidiuretic
hormone vasopressin.
 Safe to be used with hyperthyroid pt.
 Contraindicated with pregnant women

35. 1. CNS stimulation:
a) Fear and anxiety.
b) Throbbing headache.
c) Restlessness, tremor, dizziness and pallor.
d) Respiratory difficulty.
1. Dysrhytmias and ventricular fibrillation are rare
but of possible consequence.
2. Increase in blood pressure → possibility of
cerebral hemorrhage and anginal episodes in
coronary patients.
3. Because of rapid inactivation, the stimulatory is
very brief.

37. 20/ 1.8 ≃11 carpule
0.2/0.01 = 20 ml.
A carpule with 1:100,000 V.C. contains 0.01 mg/ml
M. P. D. = 0.2 mg/appointment
For example epinephrin

38.  Physiologic salt sol. (NaCl 0.9% or ringer)
 Isotonicity of LA sol.
 Hypotonic
 hypertonic

39.  Sodium bisulphite ↣ Sodium bisulphate
 Methylparaben

40. Medical problem Avoid May use
Anaesthetic allergy Same class Different class
Bisulfite allergy
LA with
V.C
plain
Sulfur allergy Articane Non-sulfur types
Severe thyrotoxicosis V.C
Plain L.A/
octapressin

41. Medical problem Avoid May use
Atypical cholinesterase Esters Amides
Severe Liver disease Amides Esters
Severe kidney disease Esters & Amides
Reduce dose or
G.A
Severe cardiovascular
disease
Excess V.C Reduce dose
Diabetic Pt. Excess V.C Reduce dose