# DENT 3005:Introduction to
# Pharmacology
# **Drugs for pain relief**
Dr Thuy Linh Truong
thuy.truong@uwa.edu.au
![]()
The University of Western Australia logo and scattered capsules and pills on a blue background.
# **DENT 3005: Introduction to Pharmacology**
# **Drugs for pain relief**
Dr Thuy Linh Truong
thuy.truong@uwa.edu.au
**Acknowledgement**
of country
The University of Western Australia acknowledges that its
campus is situated on Noongar land, and that Noongar
people remain the spiritual and cultural custodians of their
land, and continue to practise their values, languages, beliefs
and knowledge.
**THE UNIVERSITY OF**
**WESTERN**
**AUSTRALIA**
Artist: Dr Richard Barry Walley OAM
# **Acknowledgement of country**
The University of Western Australia acknowledges that its campus is situated on Noongar land, and that Noongar people remain the spiritual and cultural custodians of their land, and continue to practise their values, languages, beliefs and knowledge.
**THE UNIVERSITY OF**
**WESTERN**
**AUSTRALIA**
Artist: Dr Richard Barry Walley OAM
**Learning Outcomes**
Learning objectives
1) Understand the different types of analgesics and their mechanism of action
2) Understand the different types of local anaesthetics and their mechanism of action
3) Understand indication, dosing direction and regimen for analgesics in the dental setting
4) Understand indication, dosing direction and common techniques for local anaesthetics in the dental setting
5) Recognise oral and dental side effects of these drugs
6) Understand drugs interactions with dental medications
7) Applied knowledge to clinical scenarios
<img ></img>
Cartoon showing a tooth receiving a local anesthetic injection, with three teeth appearing to be sleeping or sedated.
# **Learning Outcomes**
## **Learning objectives**
1) Understand the different types of analgesics and their mechanism of action
2) Understand the different types of local anaesthetics and their mechanism of action
3) Understand indication, dosing direction and regimen for analgesics in the dental setting
4) Understand indication, dosing direction and common techniques for local anaesthetics in the dental setting
5) Recognise oral and dental side effects of these drugs
6) Understand drugs interactions with dental medications
7) Applied knowledge to clinical scenarios
Cartoon showing a tooth receiving a local anesthetic injection, with three teeth appearing to be sleeping or sedated.
# Pain
* **Type**
* Nociceptive
* Neuropathic
* Mixed
* **Severity**
* Subjective
* Assess behavior if patient unable to report pain
* **Pain Scales**
* Numerical
* Visual
* Verbal
* **Duration**
* Acute
* Chronic
| Verbal Pain Intensity Scale | Visual Analogue Scale |
| :---: | :---: |
| No Pain - Mild Pain - Moderate Pain - Severe Pain - Very Severe Pain - Worst Possible Pain | No Pain - Worst Possible Pain |
| **0-10 Numeric Pain Intensity Scale** | **Wong-Baker FACES® Pain Rating Scale** |
| 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 | |
| No Pain - Moderate Pain - Worst Possible Pain | 0 No Hurt - 2 Hurts Little Bit - 4 Hurts Little More - 6 Hurts Even More - 8 Hurts Whole Lot - 10 Hurts Worst |
![]()
Wong-Baker FACES Pain Rating Scale showing faces from happy (0) to crying (10) with descriptions of pain levels.
# **Pain**
## **Type**
- Nociceptive
- Neuropathic
- Mixed
## **Severity**
- Subjective
- Assess behavior if patient unable to report pain
## **Pain Scales**
- Numerical
- Visual
- Verbal
## **Duration**
- Acute
- Chronic
| Verbal Pain Intensity Scale | Visual Analogue Scale |
| :---: | :---: |
| No Pain - Mild Pain - Moderate Pain - Severe Pain - Very Severe Pain - Worst Possible Pain | No Pain - Worst Possible Pain |
| **0-10 Numeric Pain Intensity Scale** | **Wong-Baker FACES® Pain Rating Scale** |
| 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 | 0 No Hurt - 2 Hurts Little Bit - 4 Hurts Little More - 6 Hurts Even More - 8 Hurts Whole Lot - 10 Hurts Worst |
| No Pain - Moderate Pain - Worst Possible Pain | |
# Acute Vs chronic
| Acute | Chronic |
| :--- | :--- |
| **Acute** | **Chronic** |
| - Defined pattern of onset, site, character, duration | - >3months |
| - Cause: identifiable | - Persist even after healing |
| - **Rational for drug use** | - **Rational for drug use** |
| o Relieve suffering | o Relieve symptoms |
| o Reduce/prevent harmful physiological & psychological effects | o Maintain/restore function |
| o Reduce transition to chronic pain | o Improve quality of life |
| o Assist rehabilitation | |
| **Practice point** | **Practice point** |
| - Treat the disease! | - Agree on realistic goals |
| - Patients on chronic opioid treatments | - Not (usually) possible to eliminate pain completely |
| | - Titrate and review regularly |
# **Acute Vs chronic**
| Acute | Chronic |
| :--- | :--- |
| - Defined pattern of onset, site, character, duration | - >3months |
| - Cause: identifiable | - Persist even after healing |
| - **Rational for drug use** | - **Rational for drug use** |
| - Relieve suffering | - Relieve symptoms |
| - Reduce/prevent harmful physiological & psychological effects | - Maintain/restore function |
| - Reduce transition to chronic pain | - Improve quality of life |
| - Assist rehabilitation | |
| - **Practice point** | - **Practice point** |
| - Treat the disease! | - Agree on realistic goals |
| - Patients on chronic opioid treatments | - Not (usually) possible to eliminate pain completely |
| | - Titrate and review regularly |
**Pain**
**Start early**
* May minimize $\to$ chronic pain
**Route of administration**
* Oral**
* Parenteral
* Other: transdermal, inhalation, epidural ...
**Additional considerations**
* Non-drug treatments
* CBT
* Heat/cold
* Massage etc...
![]()
A man holding his jaw in pain, which is highlighted with red indicating the area of pain (likely a toothache or jaw pain). The image illustrates the theme of 'Pain' discussion.
# **Pain Management Principles**
## **Start early**
- May minimize $\to$ chronic pain
## **Route of administration**
- Oral
- Parenteral
- Other: transdermal, inhalation, epidural ...
## **Additional considerations**
- Non-drug treatments
- CBT
- Heat/cold
- Massage etc...
The **WHO analgesic ladder**
* Step by step
* Patients receive medication in increasing doses based on pain severity
* Titrate dose against
* Three steps
* Non-opioid analgesics
* Weak opioids
* Strong opioids
**Additional considerations**
* Adjuvants
* Maintained effective dose
* Starting at the bottom is not always necessary
* Pros and cons of each tx
<div class="mermaid">
graph TD
subgraph Pain Ladder
4[Interventional treatments +/- nonopioid +/- adjuvant therapy **SEVERE to VERY SEVERE PAIN**]
3['Strong' opioid +/- nonopioid +/- adjuvant therapy **MODERATE to SEVERE PAIN**]
2['Weak' opioid or multimodal +/- nonopioid +/- adjuvant therapy **MILD to MODERATE PAIN**]
1[Nonopioid + adjuvant therapy **MILD PAIN**]
end
Pain_Persistence[Pain persists or worsens]
Pain_Persistence --> 1
1 --> 2
2 --> 3
3 --> 4
subgraph Breakthrough Pain
Acute[Acute]
Intermediate[Intermediate]
Chronic[Chronic]
end
subgraph Duration of Action
Short_acting[Short-acting]
Intermediate_acting[Intermediate-acting]
Long_acting[Long-acting]
end
direction LR
Acute --> Intermediate
Intermediate --> Chronic
style Acute fill:lightblue
style Intermediate fill:lightblue
style Chronic fill:lightblue
Rapid_acting[Rapid-acting]
Rapid_acting --> Breakthrough[Breakthrough]
Breakthrough --> Acute
Breakthrough --> Intermediate
Breakthrough --> Chronic
Short_acting --> Acute
Intermediate_acting --> Intermediate
Long_acting --> Chronic
</div>
Figure 3. An updated version of the 1986 WHO pain ladder. Persistent and chronic pain syndromes should be treated with long-acting opioids; rapid-onset opioids are appropriate for breakthrough pain. A fourth step has been added for "very severe" pain that can be treated with peripheral nerve blockade.
# **The WHO analgesic ladder**
- Step by step
- Patients receive medication in increasing doses based on pain severity
- Titrate dose against
- Three steps
- Non-opioid analgesics
- Weak opioids
- Strong opioids
## **Additional considerations**
- Adjuvants
- Maintained effective dose
- Starting at the bottom is not always necessary
- Pros and cons of each tx
<div class="mermaid">
graph TD
subgraph Pain Ladder
4[Interventional treatments +/- nonopioid +/- adjuvant therapy **SEVERE to VERY SEVERE PAIN**]
3['Strong' opioid +/- nonopioid +/- adjuvant therapy **MODERATE to SEVERE PAIN**]
2['Weak' opioid or multimodal +/- nonopioid +/- adjuvant therapy **MILD to MODERATE PAIN**]
1[Nonopioid + adjuvant therapy **MILD PAIN**]
end
Pain_Persistence[Pain persists or worsens]
Pain_Persistence --> 1
1 --> 2
2 --> 3
3 --> 4
subgraph Breakthrough Pain
Acute[Acute]
Intermediate[Intermediate]
Chronic[Chronic]
end
subgraph Duration of Action
Short_acting[Short-acting]
Intermediate_acting[Intermediate-acting]
Long_acting[Long-acting]
end
direction LR
Acute --> Intermediate
Intermediate --> Chronic
style Acute fill:lightblue
style Intermediate fill:lightblue
style Chronic fill:lightblue
Rapid_acting[Rapid-acting]
Rapid_acting --> Breakthrough[Breakthrough]
Breakthrough --> Acute
Breakthrough --> Intermediate
Breakthrough --> Chronic
Short_acting --> Acute
Intermediate_acting --> Intermediate
Long_acting --> Chronic
</div>
Figure 3. An updated version of the 1986 WHO pain ladder. Persistent and chronic pain syndromes should be treated with long-acting opioids; rapid-onset opioids are appropriate for breakthrough pain. A fourth step has been added for "very severe" pain that can be treated with peripheral nerve blockade.
# Pain types and analgesia
| Drugs | Nociceptive pain | Neuropathic pain |
| :--- | :--- | :--- |
| Paracetamol | Effective, regular and maximum dosing, nil anti-inflammatory effect | Less effective |
| Opioids | Effective | May be effective |
| NSAIDS | Effective (inflammatory pain) | Less effective |
| Antidepressants, antiepileptics, LAs | Rarely used | May be effective (TCAs & antiepileptics tx of choice) |
Pain may be mixed
# **Pain types and analgesia**
| Drugs | Nociceptive pain | Neuropathic pain |
| :--- | :--- | :--- |
| Paracetamol | Effective, regular and maximum dosing, nil anti-inflammatory effect | Less effective |
| Opioids | Effective | May be effective |
| NSAIDS | Effective (inflammatory pain) | Less effective |
| Antidepressants, antiepileptics, LAs | Rarely used | May be effective (TCAs & antiepileptics tx of choice) |
Pain may be mixed
## Orofacial pain
* Many causes
* Only some are dental
* Refer for non-dental origin
* Patient assessment crucial
* Diagnosis
* Treatment planning
* Acute dental pain
* Pulpitis, post-exo pain
* Chronic dental pain
* TMD, BMS $\rightarrow$ refer
* Analgesics: adjunct only
* Does not replace **TREATMENT**
![]()
A dental professional attending to a female patient who is experiencing orofacial pain.
## **Orofacial pain**
- Many causes
- Only some are dental
- Refer for non-dental origin
- Patient assessment crucial
- Diagnosis
- Treatment planning
- Acute dental pain
- Pulpitis, post-exo pain
- Chronic dental pain
- TMD, BMS $\rightarrow$ refer
- Analgesics: adjunct only
- Does not replace **TREATMENT**
**Non-opioid analgesics: Paracetamol**
* **MOA:** Not fully determined
* Maybe: inhibition of central prostaglandin synthesis
* Negligible anti-inflammatory effect
* **Drug interactions**
* Very few clinically significant drug interactions
* Potentiation of hepatotoxicity in overdosage
* **ADR [common]**
* Hepatotoxicity (overdose)
* Hypersensitivity reactions (rare)
| **Generic name** | **Brand Name** |
| :--- | :--- |
| Paracetamol | Panadol |
| **Route** | **Absorption** | **Time to peak** | **Time to effect** |
| :--- | :--- | :--- | :--- |
| Oral | Rapid | 10-60 minutes | 15-30 minutes |
| IV | Rapid | 15 minutes | 5-10 minutes |
| Rectal | Slow, erratic | Slow, erratic | Slow, erratic |
**Dosage**
Adult, child >12yo
* 0.5-1g every 4-6 hours, max 4g per 24hours
* CR 665mg: 2 tabs every 6-8 hours, max 6 tabs per day
Child >1month
* 15mg/kg every 4-6 hours
# **Non-opioid analgesics**
## **Paracetamol**
- **MOA:** Not fully determined
- Maybe: inhibition of central prostaglandin synthesis
- Negligible anti-inflammatory effect
- **Drug interactions**
- Very few clinically significant drug interactions
- Potentiation of hepatotoxicity in overdosage
- **ADR [common]**
- Hepatotoxicity (overdose)
- Hypersensitivity reactions (rare)
| **Generic name** | **Brand Name** |
| :--- | :--- |
| Paracetamol | Panadol |
| **Route** | **Absorption** | **Time to peak** | **Time to effect** |
| :--- | :--- | :--- | :--- |
| Oral | Rapid | 10-60 minutes | 15-30 minutes |
| IV | Rapid | 15 minutes | 5-10 minutes |
| Rectal | Slow, erratic | Slow, erratic | Slow, erratic |
### **Dosage**
- **Adult, child >12yo**
- 0.5-1g every 4-6 hours, max 4g per 24hours
- CR 665mg: 2 tabs every 6-8 hours, max 6 tabs per day
- **Child >1month**
- 15mg/kg every 4-6 hours
<table>
<thead>
<tr>
<th colspan="2">Nonselective NSAIDs (COX1&amp;2-Inh)</th>
<th colspan="2">Selective NSAIDs (COX2-Inh)</th>
</tr>
<tr>
<th>Generic name</th>
<th>Brand Name</th>
<th>Generic name</th>
<th>Brand Name</th>
</tr>
</thead>
<tbody>
<tr>
<td>Aspirin</td>
<td>Solprin</td>
<td>Celecoxib</td>
<td>Celebrex</td>
</tr>
<tr>
<td>Diclofenac</td>
<td>Voltaren</td>
<td>Etoricoxib</td>
<td>Arcoxia</td>
</tr>
<tr>
<td>Ibuprofen</td>
<td>Nurofen</td>
<td>Meloxicam</td>
<td>Melobic, Mobic</td>
</tr>
<tr>
<td>Indomethacin</td>
<td>Arthrexin</td>
<td>Parecoxib</td>
<td>Dynastat inj</td>
</tr>
<tr>
<td>Ketorolac</td>
<td>Indocid</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Mefenamic Acid</td>
<td>Toradol</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Naproxen</td>
<td>Inza, Naprosyn</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Piroxicam</td>
<td>Feldene-D, Mobilis</td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
## **NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)**
<table>
<thead>
<tr>
<th colspan="2">Nonselective NSAIDs (COX1&amp;2-Inh)</th>
<th colspan="2">Selective NSAIDs (COX2-Inh)</th>
</tr>
<tr>
<th>Generic name</th>
<th>Brand Name</th>
<th>Generic name</th>
<th>Brand Name</th>
</tr>
</thead>
<tbody>
<tr>
<td>Aspirin</td>
<td>Solprin</td>
<td>Celecoxib</td>
<td>Celebrex</td>
</tr>
<tr>
<td>Diclofenac</td>
<td>Voltaren</td>
<td>Etoricoxib</td>
<td>Arcoxia</td>
</tr>
<tr>
<td>Ibuprofen</td>
<td>Nurofen</td>
<td>Meloxicam</td>
<td>Melobic, Mobic</td>
</tr>
<tr>
<td>Indomethacin</td>
<td>Arthrexin</td>
<td>Parecoxib</td>
<td>Dynastat inj</td>
</tr>
<tr>
<td>Ketorolac</td>
<td>Indocid</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Mefenamic Acid</td>
<td>Toradol</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Naproxen</td>
<td>Inza, Naprosyn</td>
<td></td>
<td></td>
</tr>
<tr>
<td>Piroxicam</td>
<td>Feldene-D, Mobilis</td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
# Opioid analgesics
* **MOA**: mimic endogenous opioids, activate opioid receptors
* **Drug interactions**
* CNS depressants
* Drugs lowering BP
* Drugs causing bradycardia
* SSRIs: Serotonin toxicity
* **ADR [common]**
* Drowsiness, dizziness, headache, orthostatic hypotension, itch, dry mouth, constipation
* Dose related respiratory depression
**Opioid analgesics**
Buprenorphine
Codeine
Aspirin with codeine
Ibuprofen with codeine
Paracetamol with codeine
Fentanyl
Hydromorphone
Methadone
Morphine
Oxycodone
Oxycodone with naloxone
Pethidine
Tapentadol
Tramadol
Tramadol with paracetamol
# **Opioid analgesics**
- **MOA**: mimic endogenous opioids, activate opioid receptors
- **Drug interactions**
- CNS depressants
- Drugs lowering BP
- Drugs causing bradycardia
- SSRIs: Serotonin toxicity
- **ADR [common]**
- Drowsiness, dizziness, headache, orthostatic hypotension, itch, dry mouth, constipation
- Dose related respiratory depression
## **Opioid Analgesics List**
- Buprenorphine
- Codeine
- Aspirin with codeine
- Ibuprofen with codeine
- Paracetamol with codeine
- Fentanyl
- Hydromorphone
- Methadone
- Morphine
- Oxycodone
- Oxycodone with naloxone
- Pethidine
- Tapentadol
- Tramadol
- Tramadol with paracetamol
In a nutshell
OPIOIDS
Drugs | Indications | Practice points |
|---|---|---|
| **Oxycodone IR (S8)** 5mg every 4-6 hours prn, max 3 days | Preferred in mod-severe acute dental pain | Always IR formulations as CR delayed onset not ideal S8 prescription rules |
| **Tramadol (S4)** 50-100mg every 4-6 hours prn, max 400mg per 24hours | Mild-mod pain | |
| | • Useful if either NSAID’s or opioids are inappropriate or contraindicated | • Beware – LOTS of potential drug interactions |
| | • Useful if excessive respiratory depression, constipation, sedation or hypoxemia with other opioids | • “Serotonin syndrome” |
| | • Useful to try to reduce overall opioid consumption | • Caution if patient is on antidepressants |
| | | • Caution if patient has epilepsy |
| | | • Caution if patient on ketamine |
| **Tapentadol (S8)** 50mg bd, max 500mg per 24hours | Mod-severe pain Alternative if patient can’t tolerate opioids | Contraindication: patients starting on irreversible non-selective MOAIs Again IR>CR S8 prescription rules |
| **Codeine (combination with paracetamol/ibuprofen) (S8)** 30-60mg every 4 hours prn, max 240mg per 24hours | Mild-mod pain Cough suppressant | Commonly combination w/ paracetamol Combinations w/ ibuprofen: subtherapeutic dose <30mg Genetic polymorphisms: lack of CYP2D6 Not for <12!!! |
| Buprenorphine, dextropropoxyphene, fentanyl, hydromorphone, methadone, morphine, pethidine | | |
| • Very strong opioids | | |
| • Patches or CR: mainly for chronic pain not acute dental pain | | |
| • Opioid depended program | | |
| • Adjunct in GA procedures | | |
## **Opioids in a Nutshell**
| Drugs | Indications | Practice points |
|---|---|---|
| **Oxycodone IR (S8)** 5mg every 4-6 hours prn, max 3 days | Preferred in mod-severe acute dental pain | Always IR formulations as CR delayed onset not ideal S8 prescription rules |
| **Tramadol (S4)** 50-100mg every 4-6 hours prn, max 400mg per 24hours | Mild-mod pain<br>• Useful if either NSAID’s or opioids are inappropriate or contraindicated<br>• Useful if excessive respiratory depression, constipation, sedation or hypoxemia with other opioids<br>• Useful to try to reduce overall opioid consumption | • Beware – LOTS of potential drug interactions<br>• “Serotonin syndrome”<br>• Caution if patient is on antidepressants<br>• Caution if patient has epilepsy<br>• Caution if patient on ketamine |
| **Tapentadol (S8)** 50mg bd, max 500mg per 24hours | Mod-severe pain Alternative if patient can’t tolerate opioids | Contraindication: patients starting on irreversible non-selective MOAIs Again IR>CR S8 prescription rules |
| **Codeine (combination with paracetamol/ibuprofen) (S8)** 30-60mg every 4 hours prn, max 240mg per 24hours | Mild-mod pain Cough suppressant | Commonly combination w/ paracetamol Combinations w/ ibuprofen: subtherapeutic dose <30mg Genetic polymorphisms: lack of CYP2D6 Not for <12!!! |
| **Buprenorphine, dextropropoxyphene, fentanyl, hydromorphone, methadone, morphine, pethidine** | • Very strong opioids<br>• Patches or CR: mainly for chronic pain not acute dental pain<br>• Opioid depended program<br>• Adjunct in GA procedures | |
**Therapeutic guide**
**analgesic regimen**
* **Mild – moderate**
* Ibuprofen 400mg every 6-8 hours ($\le$5days) + paracetamol 1000mg q4-6h (4g/24hrs)
* Celecoxib 100mg **bd** ($\le$5days)
* Unless NSAIDs contraindicated
* **Severe acute**
* Ibuprofen 400mg every 6-8 hours ($\le$5days) **OR** celecoxib
* + paracetamol 1000mg every 4-6 hours (4g/24hrs)
* + Oxycodone 5mg every 4-6 hours prn ($\le$3days)
* Unless NSAIDs contraindicated
VERSION 3
# **Therapeutic guide: analgesic regimen**
- **Mild – moderate**
- Ibuprofen 400mg every 6-8 hours ($\le$5days) + paracetamol 1000mg q4-6h (4g/24hrs)
- Celecoxib 100mg **bd** ($\le$5days)
- Unless NSAIDs contraindicated
- **Severe acute**
- Ibuprofen 400mg every 6-8 hours ($\le$5days) **OR** celecoxib
- + paracetamol 1000mg every 4-6 hours (4g/24hrs)
- + Oxycodone 5mg every 4-6 hours prn ($\le$3days)
- Unless NSAIDs contraindicated
VERSION 3
# Local Anesthetics
**Introduction**
* A drug that causes reversible loss of sensation
* Used to numb specific areas of the body
* Allows pain-free dental procedures
* Blocks nerve conduction temporarily
* Does not affect consciousness
* Used both topically and via injection
**History**
* Cocaine was the first local anaesthetic
* Introduced in dental use in the late 1800s
* Safer synthetic alternatives developed later
* Procaine (Novocain) was an early alternative
* Lidocaine introduced in the 1940s
# **Local Anesthetics**
## **Introduction**
- A drug that causes reversible loss of sensation
- Used to numb specific areas of the body
- Allows pain-free dental procedures
- Blocks nerve conduction temporarily
- Does not affect consciousness
- Used both topically and via injection
## **History**
- Cocaine was the first local anaesthetic
- Introduced in dental use in the late 1800s
- Safer synthetic alternatives developed later
- Procaine (Novocain) was an early alternative
- Lidocaine introduced in the 1940s
## General Vs Local Anesthesia
| General | Local |
| :--- | :--- |
| • **Effect**: Affects your entire body | • **Effect**: Numbs a **small, specific area** of your body |
| • **Consciousness**: You are **completely unconscious** (asleep) and unaware of what's happening | • **Consciousness**: You stay **awake and alert** |
| • **Use**: For major surgeries (e.g., heart surgery, brain surgery, or operations on internal organs) | • **Use**: Minor procedures (e.g., dental work, stitches, mole removal) |
| • **How it's given**: Through a mask (gas) or an IV injection | • **How it's given**: Usually injected directly into the area being treated |
| • **Risks/Side Effects**: Drowsiness, nausea, confusion after waking up; requires careful monitoring of heart, breathing, etc. | • **Risks/Side Effects**: Very few; may feel tingling or numbness for a while afterward |
## **General Vs Local Anesthesia**
| General | Local |
| :--- | :--- |
| • **Effect**: Affects your entire body | • **Effect**: Numbs a **small, specific area** of your body |
| • **Consciousness**: You are **completely unconscious** (asleep) and unaware of what's happening | • **Consciousness**: You stay **awake and alert** |
| • **Use**: For major surgeries (e.g., heart surgery, brain surgery, or operations on internal organs) | • **Use**: Minor procedures (e.g., dental work, stitches, mole removal) |
| • **How it's given**: Through a mask (gas) or an IV injection | • **How it's given**: Usually injected directly into the area being treated |
| • **Risks/Side Effects**: Drowsiness, nausea, confusion after waking up; requires careful monitoring of heart, breathing, etc. | • **Risks/Side Effects**: Very few; may feel tingling or numbness for a while afterward |
**Local Anesthetics**
| MOA | Types |
|---|---|
| **Blocks sodium channels in nerve membranes** | • **Amides:** Lidocaine, Articaine, Mepivacaine |
| • **Prevents initiation of nerve impulses** | • **Esters:** Procaine, Benzocaine |
| • **Stops pain signals from reaching the brain** | • Amides metabolized in liver |
| • **Works only on peripheral nerves** | • Esters metabolized in plasma |
| • **Action is reversible and dose-dependent** | • Articaine has both amide & ester properties |
| • **Onset and duration vary by agent** | |
## **Local Anesthetics: MOA and Types**
| MOA | Types |
|---|---|
| **Blocks sodium channels in nerve membranes** | • **Amides:** Lidocaine, Articaine, Mepivacaine |
| • **Prevents initiation of nerve impulses** | • **Esters:** Procaine, Benzocaine |
| • **Stops pain signals from reaching the brain** | • Amides metabolized in liver |
| • **Works only on peripheral nerves** | • Esters metabolized in plasma |
| • **Action is reversible and dose-dependent** | • Articaine has both amide & ester properties |
| • **Onset and duration vary by agent** | |
# Local Anesthetics
| Indications | Common techniques |
| :--- | :--- |
| **•** Tooth extractions | **•** Infiltration anaesthesia |
| **•** Root canal treatments | **•** Nerve block anaesthesia |
| **•** Restorative procedures (fillings) | **•** Intra-ligamentary injections |
| **•** Periodontal therapy | **•** Intra-pulpal injections |
| **•** Minor oral surgeries | **•** Topical anaesthesia before injection |
| | **•** Computer-controlled delivery systems |
## **Local Anesthetics: Indications and Techniques**
| Indications | Common techniques |
| :--- | :--- |
| **•** Tooth extractions | **•** Infiltration anaesthesia |
| **•** Root canal treatments | **•** Nerve block anaesthesia |
| **•** Restorative procedures (fillings) | **•** Intra-ligamentary injections |
| **•** Periodontal therapy | **•** Intra-pulpal injections |
| **•** Minor oral surgeries | **•** Topical anaesthesia before injection |
| | **•** Computer-controlled delivery systems |
**Local complications of local anaesthesia**
* Neurological: paraesthesia, dysaesthesia, temporary facial nerve paralysis
* Prolonged anaesthesia usually resolves; permanent anaesthesia is rare
* Nerve injuries from trauma, bleeding, or neurotoxicity
* Increased risk with repeat injections or high concentrations
* Tissue trauma: haematoma, accidental intramuscular injection $\to$ trismus
* Rare equipment-related issues (e.g., cartridge explosions)
## **Local complications of local anaesthesia**
- Neurological: paraesthesia, dysaesthesia, temporary facial nerve paralysis
- Prolonged anaesthesia usually resolves; permanent anaesthesia is rare
- Nerve injuries from trauma, bleeding, or neurotoxicity
- Increased risk with repeat injections or high concentrations
- Tissue trauma: haematoma, accidental intramuscular injection $\to$ trismus
- Rare equipment-related issues (e.g., cartridge explosions)
**Systemic toxicity of local anaesthetics**
* Causes: intravascular injection, overdose, rapid absorption
* Prevention: use lowest effective dose, aspirate before injection
* Early signs: anxiety, dizziness, tremors
* Severe signs: seizures, cardiovascular collapse, methemoglobinemia
* Actions: stop injection, support ABCs, consider lipid therapy
## **Systemic toxicity of local anaesthetics**
- **Causes:** intravascular injection, overdose, rapid absorption
- **Prevention:** use lowest effective dose, aspirate before injection
- **Early signs:** anxiety, dizziness, tremors
- **Severe signs:** seizures, cardiovascular collapse, methemoglobinemia
- **Actions:** stop injection, support ABCs, consider lipid therapy
**Local Anesthetics & vasoconstrictors**
* Local anaesthetics can be combined with a vasoconstrictor to prolong effects
* Vasoconstrictors slow anaesthetic absorption and reduce bleeding
* Adrenaline (epinephrine) is commonly used in dental practice
* Avoid adrenaline in patients sensitive to sulfites
* Alternatives: Felypressin or adrenaline-free solutions
* Felypressin is safe for pregnant patients and has minimal cardiac effects
## **Local Anesthetics & vasoconstrictors**
- Local anaesthetics can be combined with a vasoconstrictor to prolong effects
- Vasoconstrictors slow anaesthetic absorption and reduce bleeding
- Adrenaline (epinephrine) is commonly used in dental practice
- Avoid adrenaline in patients sensitive to sulfites
- Alternatives: Felypressin or adrenaline-free solutions
- Felypressin is safe for pregnant patients and has minimal cardiac effects
<table>
<thead>
<tr>
<td>**Local Anaesthetic**</td>
<td>**Comments**</td>
</tr>
</thead>
<tbody>
<tr>
<td>**Short- to Intermediate-Acting Preparations**</td>
<td></td>
</tr>
<tr>
<td>Lidocaine</td>
<td>Shorter acting—use in dentistry may be limited</td>
</tr>
<tr>
<td>Lidocaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting, first line for routine dental procedures</td>
</tr>
<tr>
<td>Prilocaine</td>
<td>Shorter acting—use in dentistry may be limited</td>
</tr>
<tr>
<td>Prilocaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting</td>
</tr>
<tr>
<td>Prilocaine with Felypressin</td>
<td>Intermediate acting, first line for routine dental procedures when adrenaline (epinephrine) is contraindicated</td>
</tr>
<tr>
<td>Mepivacaine</td>
<td>Shorter acting—use in dentistry may be limited, do not use in children younger than 3 years</td>
</tr>
<tr>
<td>Mepivacaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting, do not use in children younger than 3 years</td>
</tr>
<tr>
<td>Articaine with Adrenaline (Epinephrine)</td>
<td>Risk of prolonged or permanent anaesthesia, for infiltration only—do not use for regional blocks (injection close to inferior alveolar, lingual and mental nerves), do not use in children younger than 4 years</td>
</tr>
<tr>
<td>**Long-Acting Preparations**</td>
<td></td>
</tr>
<tr>
<td>Ropivacaine</td>
<td>Useful for situations in which prolonged analgesia (eg 12 to 18 hours) is required, postoperative pain, and refractory acute dental pain, concentrations up to 0.5% can be used in children</td>
</tr>
<tr>
<td>Bupivacaine</td>
<td>Similar indications to ropivacaine, more cardiotoxic than ropivacaine, cardiac toxicity may manifest before neurological toxicity, do not use in children younger than 12 years</td>
</tr>
<tr>
<td>Bupivacaine with Adrenaline (Epinephrine)</td>
<td>Similar indications to ropivacaine, more cardiotoxic than ropivacaine, cardiac toxicity may manifest before neurological toxicity, do not use in children younger than 12 years</td>
</tr>
</tbody>
</table>
## **Local Anesthetic Preparations**
<table>
<thead>
<tr>
<td><strong>Local Anaesthetic</strong></td>
<td><strong>Comments</strong></td>
</tr>
</thead>
<tbody>
<tr>
<td><strong>Short- to Intermediate-Acting Preparations</strong></td>
<td></td>
</tr>
<tr>
<td>Lidocaine</td>
<td>Shorter acting—use in dentistry may be limited</td>
</tr>
<tr>
<td>Lidocaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting, first line for routine dental procedures</td>
</tr>
<tr>
<td>Prilocaine</td>
<td>Shorter acting—use in dentistry may be limited</td>
</tr>
<tr>
<td>Prilocaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting</td>
</tr>
<tr>
<td>Prilocaine with Felypressin</td>
<td>Intermediate acting, first line for routine dental procedures when adrenaline (epinephrine) is contraindicated</td>
</tr>
<tr>
<td>Mepivacaine</td>
<td>Shorter acting—use in dentistry may be limited, do not use in children younger than 3 years</td>
</tr>
<tr>
<td>Mepivacaine with Adrenaline (Epinephrine)</td>
<td>Intermediate acting, do not use in children younger than 3 years</td>
</tr>
<tr>
<td>Articaine with Adrenaline (Epinephrine)</td>
<td>Risk of prolonged or permanent anaesthesia, for infiltration only—do not use for regional blocks (injection close to inferior alveolar, lingual and mental nerves), do not use in children younger than 4 years</td>
</tr>
<tr>
<td><strong>Long-Acting Preparations</strong></td>
<td></td>
</tr>
<tr>
<td>Ropivacaine</td>
<td>Useful for situations in which prolonged analgesia (eg 12 to 18 hours) is required, postoperative pain, and refractory acute dental pain, concentrations up to 0.5% can be used in children</td>
</tr>
<tr>
<td>Bupivacaine</td>
<td>Similar indications to ropivacaine, more cardiotoxic than ropivacaine, cardiac toxicity may manifest before neurological toxicity, do not use in children younger than 12 years</td>
</tr>
<tr>
<td>Bupivacaine with Adrenaline (Epinephrine)</td>
<td>Similar indications to ropivacaine, more cardiotoxic than ropivacaine, cardiac toxicity may manifest before neurological toxicity, do not use in children younger than 12 years</td>
</tr>
</tbody>
</table>
**Dosages in dentistry**
- Use the lowest effective dose of local anaesthetic to prevent dental pain
- Maximum safe doses are listed for different local anaesthetics in dental cartridges and other forms
- The required dose is often much lower than the maximum safe dose if administered correctly
- The appropriate dose depends on the area, tissue vascularity, method, and patient condition
- Children, especially young ones, are more susceptible to overdose and may require lower doses
- Elderly patients may need reduced doses due to age-related physiological changes
## **Dosages in dentistry**
- Use the lowest effective dose of local anaesthetic to prevent dental pain
- Maximum safe doses are listed for different local anaesthetics in dental cartridges and other forms
- The required dose is often much lower than the maximum safe dose if administered correctly
- The appropriate dose depends on the area, tissue vascularity, method, and patient condition
- Children, especially young ones, are more susceptible to overdose and may require lower doses
- Elderly patients may need reduced doses due to age-related physiological changes
**Dosages in dentistry**
Here’s a simple way to calculate the maximum safe volume of local anaesthetic for a
patient
1. Find the maximum dose per kg for the drug (for lidocaine with adrenaline, it's 7 mg/kg)
2. Multiply this by the patient's weight in kg to get the total max dose in mg.
Example: 7 mg/kg × 70 kg = 490 mg
3. Convert this dose to volume using the drug concentration (lidocaine 2% = 20 mg/mL)
490 mg ÷ 20 mg/mL = 24.5 mL
4. Convert volume to dental cartridges (each cartridge is 2.2 mL)
24.5 mL ÷ 2.2 mL = about 11 cartridges
5. So, for a 70 kg patient, you should not exceed 24.5 mL or 11 cartridges of 2% lidocaine with adrenaline in a single dose
## **Calculating Maximum Safe Volume**
Here’s a simple way to calculate the maximum safe volume of local anaesthetic for a patient:
1. Find the maximum dose per kg for the drug (for lidocaine with adrenaline, it's 7 mg/kg).
2. Multiply this by the patient's weight in kg to get the total max dose in mg.
3. Convert this dose to volume using the drug concentration (lidocaine 2% = 20 mg/mL).
4. Convert volume to dental cartridges (each cartridge is 2.2 mL).
**Figure 13.36 A worked example of calculating the maximum volume of a safe single dose of local anaesthetic**
A 70 kg patient requires a local anaesthetic for a dental procedure. Lidocaine 2% (20 mg/mL) with adrenaline (epinephrine) 1:80 000 (12.5 micrograms/mL) will be used [NB1].
**Calculate the maximum dose in milligrams based on the patient's weight**
maximum safe single dose of lidocaine with adrenaline is 7 mg/kg
7 mg/kg $\times$ 70 kg = 490 mg
**Use the concentration of solution (mg/mL) to convert the calculated dose to volume**
490 mg $\div$ 20 mg/mL = 24.5 mL
**Convert the calculated volume to number of 2.2 mL dental cartridges [NB2]**
24.5 mL $\div$ 2.2 mL/cartridge = 11 cartridges
**Therefore, the total volume administered must not exceed 24.5 mL or 11 cartridges containing 2.2 mL each.**
NB1: To convert a percentage concentration to mg/mL, multiply by 10 (eg 2% = 20 mg/mL).
NB2: Dental cartridges are available in a variety of volumes (eg 1.7 mL, 1.8 mL, 2.2 mL).
### **Figure 13.36 A worked example of calculating the maximum volume of a safe single dose of local anaesthetic**
A 70 kg patient requires a local anaesthetic for a dental procedure. Lidocaine 2% (20 mg/mL) with adrenaline (epinephrine) 1:80 000 (12.5 micrograms/mL) will be used [NB1].
1. **Calculate the maximum dose in milligrams based on the patient's weight**
- maximum safe single dose of lidocaine with adrenaline is 7 mg/kg
- 7 mg/kg $\times$ 70 kg = 490 mg
2. **Use the concentration of solution (mg/mL) to convert the calculated dose to volume**
- 490 mg $\div$ 20 mg/mL = 24.5 mL
3. **Convert the calculated volume to number of 2.2 mL dental cartridges [NB2]**
- 24.5 mL $\div$ 2.2 mL/cartridge = 11 cartridges
**Therefore, the total volume administered must not exceed 24.5 mL or 11 cartridges containing 2.2 mL each.**
- **NB1:** To convert a percentage concentration to mg/mL, multiply by 10 (eg 2% = 20 mg/mL).
- **NB2:** Dental cartridges are available in a variety of volumes (eg 1.7 mL, 1.8 mL, 2.2 mL).
<table>
<thead>
<tr>
<th>Local Anaesthetic</th>
<th>Concentration</th>
<th>Adrenaline (Epinephrine)</th>
<th>Maximum mg/kg Dose</th>
<th>Approximate Maximum Volume for 70 kg Adult</th>
<th>Approximate Maximum Volume for 20 kg Child</th>
</tr>
</thead>
<tbody>
<tr>
<td>Lidocaine</td>
<td>2% (20 mg/mL)</td>
<td>1:80,000 (12.5 mcg/mL)</td>
<td>7 mg/kg</td>
<td>24.5 mL</td>
<td>7 mL</td>
</tr>
<tr>
<td>Mepivacaine</td>
<td>2% (20 mg/mL)</td>
<td>1:100,000 (10 mcg/mL)</td>
<td>Not specified</td>
<td>See below</td>
<td>See below</td>
</tr>
<tr>
<td>Mepivacaine (Child)</td>
<td>3% (30 mg/mL)</td>
<td colspan="4">Aust product information<br>Child (3–6 years): 1.8 mL<br>Child (6–14 years): 2.7 mL<br>Adolescent (14–17 years): 4.4 mL</td>
</tr>
<tr>
<td>Mepivacaine (Adolescent/Adult)</td>
<td>3% (30 mg/mL)</td>
<td colspan="4">Adult: 6.6 mL</td>
</tr>
<tr>
<td>Prilocaine</td>
<td>3% (30 mg/mL)</td>
<td>Felypressin 0.03 IU/mL</td>
<td>9 mg/kg</td>
<td>21 mL</td>
<td>6 mL</td>
</tr>
<tr>
<td>Prilocaine (Adrenaline)</td>
<td>3% (30 mg/mL)</td>
<td>1:300,000 (3.3 mcg/mL)</td>
<td>9 mg/kg</td>
<td>21 mL</td>
<td>6 mL</td>
</tr>
<tr>
<td>Prilocaine (4%)</td>
<td>4% (40 mg/mL)</td>
<td>-</td>
<td>6 mg/kg</td>
<td>10.5 mL</td>
<td>3 mL</td>
</tr>
<tr>
<td>Articaine</td>
<td>4% (40 mg/mL)</td>
<td>1:100,000 (10 mcg/mL)</td>
<td>7 mg/kg</td>
<td>12.25 mL</td>
<td>3.5 mL</td>
</tr>
<tr>
<td>Articaine (1:200,000)</td>
<td>4% (40 mg/mL)</td>
<td>1:200,000 (5 mcg/mL)</td>
<td>7 mg/kg</td>
<td>12.25 mL</td>
<td>3.5 mL</td>
</tr>
</tbody>
</table>
## **Maximum Dosage Table**
<table>
<thead>
<tr>
<th>Local Anaesthetic</th>
<th>Concentration</th>
<th>Adrenaline (Epinephrine)</th>
<th>Maximum mg/kg Dose</th>
<th>Approximate Maximum Volume for 70 kg Adult</th>
<th>Approximate Maximum Volume for 20 kg Child</th>
</tr>
</thead>
<tbody>
<tr>
<td>Lidocaine</td>
<td>2% (20 mg/mL)</td>
<td>1:80,000 (12.5 mcg/mL)</td>
<td>7 mg/kg</td>
<td>24.5 mL</td>
<td>7 mL</td>
</tr>
<tr>
<td>Mepivacaine</td>
<td>2% (20 mg/mL)</td>
<td>1:100,000 (10 mcg/mL)</td>
<td>Not specified</td>
<td>See below</td>
<td>See below</td>
</tr>
<tr>
<td>Mepivacaine (Child)</td>
<td>3% (30 mg/mL)</td>
<td colspan="4">Aust product information<br>Child (3–6 years): 1.8 mL<br>Child (6–14 years): 2.7 mL<br>Adolescent (14–17 years): 4.4 mL</td>
</tr>
<tr>
<td>Mepivacaine (Adolescent/Adult)</td>
<td>3% (30 mg/mL)</td>
<td colspan="4">Adult: 6.6 mL</td>
</tr>
<tr>
<td>Prilocaine</td>
<td>3% (30 mg/mL)</td>
<td>Felypressin 0.03 IU/mL</td>
<td>9 mg/kg</td>
<td>21 mL</td>
<td>6 mL</td>
</tr>
<tr>
<td>Prilocaine (Adrenaline)</td>
<td>3% (30 mg/mL)</td>
<td>1:300,000 (3.3 mcg/mL)</td>
<td>9 mg/kg</td>
<td>21 mL</td>
<td>6 mL</td>
</tr>
<tr>
<td>Prilocaine (4%)</td>
<td>4% (40 mg/mL)</td>
<td>-</td>
<td>6 mg/kg</td>
<td>10.5 mL</td>
<td>3 mL</td>
</tr>
<tr>
<td>Articaine</td>
<td>4% (40 mg/mL)</td>
<td>1:100,000 (10 mcg/mL)</td>
<td>7 mg/kg</td>
<td>12.25 mL</td>
<td>3.5 mL</td>
</tr>
<tr>
<td>Articaine (1:200,000)</td>
<td>4% (40 mg/mL)</td>
<td>1:200,000 (5 mcg/mL)</td>
<td>7 mg/kg</td>
<td>12.25 mL</td>
<td>3.5 mL</td>
</tr>
</tbody>
</table>
References
- Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier; 2023
- Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Analgesics; [updated 2025; cited 2025]. Available from: UWA Onesearch
- Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Immunomodulators and anti-inflammatories; [updated 2025; cited 2025]. Available from: UWA Onesearch
- Oral and Dental Expert Group. *Therapeutic Guidelines Oral and Dental (Version 3)*. Therapeutic Guidelines Ltd:2019
- Pharmaceutical Society of Australia. *Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice*. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021
- MIMS Australia. *eMIMSelite: Consumer medicine information, specific clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. Available from: UWA Onesearch
- Malamed SF. *Handbook of local anesthesia*. 6th ed. St. Louis (MO): Elsevier Mosby; 2013
<img alt="The image displays illustrations related to medicine and pharmacology. The top right shows a person with a possible cold or allergy surrounded by flowers and various pills and a bottle. Below this are illustrations of prescription bottles with pills. The bottom right features a diagram explaining pharmacodynamics, showing how different types of drugs (Agonist, Antagonist, Partial Agonist) interact with receptors on a cell." />
# **References**
- Ritter JM, Flower RJ, Henderson G, Loke YK, MacEwan D, Robinson E, editors. *Rang & Dale’s pharmacology*. 10th ed. Edinburgh: Elsevier; 2023
- Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Analgesics; [updated 2025; cited 2025]. Available from: UWA Onesearch
- Australian Medicines Handbook Online [Internet]. Adelaide (AU): Australian Medicines Handbook Pty Ltd;2000. Immunomodulators and anti-inflammatories; [updated 2025; cited 2025]. Available from: UWA Onesearch
- Oral and Dental Expert Group. *Therapeutic Guidelines Oral and Dental (Version 3)*. Therapeutic Guidelines Ltd:2019
- Pharmaceutical Society of Australia. *Australian Pharmaceutical Formulary and Handbook: A Guide to Best Practice*. 25th ed. Canberra: Pharmaceutical Society of Australia; 2021
- MIMS Australia. *eMIMSelite: Consumer medicine information, specific clinical monograph* [Internet]. Sydney: MIMS Australia; [updated 2025; cited 2025 Apr 17]. Available from: UWA Onesearch
- Malamed SF. *Handbook of local anesthesia*. 6th ed. St. Louis (MO): Elsevier Mosby; 2013
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