Course overview Upon completing this intermediate-level course, the learner will be able to discuss the differences among local anesthetics typically administered by oral healthcare professionals. The course will also fill gaps in knowledge concerning the selection, timing, and dosage of appropriate anesthetics for certain special
populations requiring advanced consideration. The principles learned will be directly applicable to the appropriate selection of local anesthetics for the cardiac, pregnant, and breast- feeding patient, as well as to the recognition and best and safest treatment of patients with a significant allergic history.
INTRODUCTION
According to the Index Medicus, since publishing the second edition of this module in 2018, there have been 764 publications on, “local anesthetic and dentistry,” circulated in the peer- reviewed literature (https://www.ncbi.nlm.nih.gov/pubmed). This updated 2021 edition incorporates the findings of these latest research papers as well as current guidelines from regulatory and professional authorities, while continuing to emphasize the founding principles of appropriate local anesthetic selection and administration. Oral healthcare professionals (OHCPs) are routinely involved with the selection and administration of local anesthetics to address patient comfort during dental procedures. Patient comfort as it relates to orofacial pain has both physiological and psychological components. Unfortunately, an experience of discomfort related to dentistry can lead patients to avoid or postpone treatment, making these patients more difficult to treat and less likely to comply with future appointments or oral healthcare treatment planning. Local anesthetics administered preoperatively help mitigate pain and improve patient comfort as well as clinical outcomes, making them an integral part of dental practice. The variety of local anesthetics available, whether combined with a vasoconstrictor or as a plain solution, offer unique pharmacological properties that allow the practitioner to tailor therapy to the individual and match the best drug to the specific patient and clinical situation. Most dental pain or discomfort is acute in nature and typically accompanied by tissue injury or inflammation. Although this pain can resolve spontaneously once the underlying cause (e.g., Cocaine The people of Peru have long depended on the leaves of the coca plant to relieve fatigue, hunger, and altitude sickness, as well as to lift the spirits, especially during long nights tending their flocks in the high mountains. Scientific interest in the psychotropic properties of this naturally occurring herbal medication led the German chemist Albert Friedrich Emil Niemann to isolate the active ingredient, cocaine (its nomenclature being derived from coca and the alkaloid suffix - ine ) and publish his findings in 1860. It would be another 20 years before Basil von Anrep would publish the results of his studies investigating the clinical application of cocaine in humans. He recommended cocaine as a surgical anesthetic, although it is the ophthalmologist Carl Koller who is usually credited with empirically demonstrating, in 1884, the benefits of cocaine use in medicine as a topical adjunct in ocular surgery Procaine The German chemist Alfred Einhorn is credited with first synthesizing procaine in 1905 (Sneader, 2005). He patented the drug under the name Novocain (from the Latin novo - [meaning new] and - caine , the common suffix for alkaloid anesthetics). Novocain was found to be safe and effective when compared to cocaine, although its anesthetic effects were weaker and some Mechanism of action All local anesthetics block the sensation of pain by interfering with the propagation of peripheral nerve impulses. They do not significantly alter the resting membrane potential of the nerve, but they do impair dynamic responses to nerve stimulation,
inflamed pulp, carious lesion, or abscessed gingiva) is definitively treated, a pharmacological approach to pain management is considered the standard of care. Local anesthetics administered prior to a dental procedure help minimize pain and improve patient comfort to allow the procedure to go forward. Excellent intraoperative pain control with the appropriate selection and dose of local anesthesia will set both the OHCP and patient up for success, especially when combined with excellent postoperative analgesic medication selection. Designed for dentists, dental hygienists, and dental assistants, this course will review the pharmacology of local anesthetic agents and update the participant on current guidelines and therapeutic choices in order to optimize prescribing practices. Since the goal of local anesthetic therapy is to ensure selection of the right drug at the right time and at the right dose, for the right patient and the right procedure, the information presented in this course should be considered essential knowledge for all OHCPs, both seasoned and newly credentialed. Upon completing this intermediate-level course, the learner will be able to discuss the differences among local anesthetics typically administered by oral healthcare professionals. The course will also fill gaps in knowledge concerning the selection, timing, and dosage of appropriate anesthetics for certain special populations requiring advanced consideration. The principles learned will be directly applicable to the appropriate selection of local anesthetics for the cardiac, pregnant, and breast- feeding patient, as well as to the recognition and best and safest treatment of patients with a significant allergic history.
HISTORICAL PERSPECTIVE
(Grzybowski, 2008). This usage continues today, usually as a 4% topical solution for both ocular and nasal surgeries (Saif, Farboud, Delfosse, Pope, & Adke, 2016; MacNeil et al., 2020). During the 1880s, the famous surgeon William Halsted was among those who demonstrated the local anesthetic potential of cocaine in nerve block anesthesia (Lathan, 2010), at around the same time that James Leonard Corning discovered the drug’s usefulness in peridural anesthesia (Loosely, 2009). Augustus Karl Gustav Bier used cocaine for spinal anesthesia in 1898 (Calthorpe, 2008). While the general acceptance of cocaine to support medical and dental procedures was widely appreciated at the turn of the century, cocaine’s potential for adverse reactions and abuse led to the investigation and discovery of much safer and non-addicting local anesthetics. patients demonstrated a strong allergic reaction, most likely due to procaine’s amino ester group (Tetzlaff, n.d.). Regardless, Novocain quickly became the standard local anesthesia, and even today, many patients refer to local anesthesia generically as “novocaine,” even though procaine is no longer used.
PHARMACOLOGY OF LOCAL ANESTHETICS
thereby inhibiting both the generation and conduction of action potentials. Although an inactive nerve membrane is relatively impermeable to sodium ions, when the nerve is stimulated, sodium
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