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Local anesthetics are very important in the field of surgery and medicine and that includes dentistry and oral maxillofacial surgery notwithstanding. They are reversible agents that block nerve conduction in a localized area when injected or applied topically. Noxious stimuli are blocked from reaching the brain hence providing pain control.
Cocaine was the first ever documented local anesthetic and it was first described by Albert Niemann who was a German chemist. He extracted and isolated cocaine from the coca shrub in 1859 not knowing the great impact it would have on the medical and surgical world in the future. Carl Koller experimented with cocaine 20 years later before William Halsted then introduced nerve blocks with cocaine. But there were a number of adverse acute and chronic effects of cocaine such as cardiac overstimulation and vasoconstriction. And of course there was the problem of physical and psychological dependence. It was not until 1904 when the ester procaine was developed that cocaine was used less regularly and they eventually stopped being used. The amide local anesthetic lidocaine was invented in the 1950s and it has been in use even till now due to its excellent anesthetic properties and little side effects.
Local anesthetics can be short acting, intermediate acting or long acting and an ideal local anesthetic will be one which provides pain control for the duration of the surgery and a little more after that. In dento alveolar surgery and wisdom tooth surgery, the local anesthetic of choice is lidocaine with adrenaline. In patients where lidocaine is contraindicated, prilocaine is used and there may be a vasoconstrictor equivalent in the form of octapressin.
In wisdom tooth surgery, the local anesthetic is given in the form of a nerve block called the inferior alveolar nerve block and a long buccal infiltration may also be given. Lidocaine on its own has little side effects with most of the side effects normally contributed by the vasoconstrictor present. The vasoconstrictors act to keep the local anesthetic in the region of the surgery for as long as possible to prolong its effects. Most of the side effects or the vasoconstrictor are on the cardiac system or the heart and that is the reason why lidocaine with adrenaline is normally contraindicated for heart patients.
Sometimes, the oral surgeon may opt to give a longer acting local anesthetic such as bupivacaine to provide longer pain control and to give the patient more comfort post operatively. Topical anesthetics may also be used to superficially numb the area to be injected. This is so when the needle is introduced the patient will not feel the needle prick. However, the pressure caused by the introduction of the local anesthetic into tissue more often than not bring about the sensation of pain itself. That is why new delivery systems are being introduced to deliver the local anesthetic at a slower rate so as to lessen this painful effect.
The traditional method of injection makes use of the local anesthetic housed in a glass cartridge loaded on a dental syringe. An injection needle is mounted on the dental syringe onto which the dental cartridge containing the local anesthetic is then placed. The oral surgeon will then introduce the local anesthetic into the area or region of desire.
The local anesthetic typically last 3 to 4 hours when lidocaine with adrenaline is used. When bupivacaine or marcaine is used however, this effect can last up to 8 hours. The patient must then take care not to accidentally bite on his lip or tongue for the time period.
After the local anesthetic wears off, the patient can start to feel the first inklings of pain and sometimes the oral surgeon might advise taking a pre surgical dose of painkillers such as non steroidal non inflammatories such as mefenemic acid or synflex. And he might also advise taking the prescribed painkillers at the regular dosage rather than taking them only when the pain comes. This will bring about better pain control. Wisdom tooth surgery may involve some bone removal and for some patients, especially those with low pain tolerance, the pain may be a very traumatic experience. But research and studies have shown that the pain can be well controlled with the painkillers that have been mentioned.
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