INDICATIONS, CONTRAINDICATIONS, AND
MAXIMUM RECOMMENDED DOSE (MRD)
OF
LOCAL
ANESTHETICS
Department of Oral and Maxillofacial
Surgery
Presented by : Chitra C.
Pradhan (23),
Devyani Mehra
(24)
TABLE
of contents
01. What is Local Anesthesia? 04. Max. Recommended Dose (MRD)
02. What are Local Anaesthetic
02. Indications of LA 05. References
Agents?
03. Contraindications of LA
What is Local
Anesthesia?
Local anesthesia has been defined as loss of
sensation in a circumscribed area of the body
caused by depression of excitation in nerve
endings or inhibition of the conduction
- Stanley
process F.
in peripheral nerves.
Malamed
Key Characteristics:
• Reversible loss of sensation
• Consciousness and vital functions are
preserved
• Achieved by local anesthetic drugs or local
anesthetics
Indications of
LAMaxillofacial Indications
• Routine and complex exodontia – including surgical removal of impacted teeth
• Pulpal and periapical therapies – such as root canal procedures and
apicoectomies
• Periodontal interventions – flap surgeries, gingivectomy, and scaling in inflamed
sites
• Pre-prosthetic and ridge modification procedures – alveoloplasty, frenectomy,
vestibuloplasty
• Soft tissue surgeries – excision or biopsy of mucosal lesions, fibromas, mucoceles
• Incision and drainage of localized odontogenic infections
• Diagnostic nerve blocks – to aid in localization of orofacial pain or neuralgias
• Adjunct in pediatric or sedation-assisted procedures – ensuring cooperation
and comfort in vulnerable populations
Contraindications
of LA
Absolute
Contraindications
Circumstances in which the use of the local anesthetic agent or its adjunct (e.g., vasoconstrictor) is
strictly prohibited due to significant risk of severe adverse outcomes.
• Documented Allergy to Local Anesthetic Agent
⚬ True allergy to ester-type agents: avoid all esters
⚬ Allergy to amide-type agents: extremely rare; consult allergist if suspected
• Documented Sulfite Sensitivity (with vasoconstrictors)
⚬ Sulfite preservatives (e.g., sodium metabisulfite) are present in epinephrine-containing solutions
• Severe Untreated Hypertension or Unstable Angina
⚬ Especially in patients requiring vasoconstrictor-containing solutions
• Severe Cardiac Dysrhythmias
⚬ Risk of arrhythmogenic effect due to epinephrine
Contraindications
of LARelative
Contraindications
Clinical scenarios in which local anesthetics may be employed cautiously, often with dose
adjustments or alternative agents, based on a comprehensive risk-benefit analysis.
• Significant Cardiovascular Disease (ASA III–IV):
⚬ Use minimal epinephrine concentrations (e.g., 1:200,000).
⚬ Avoid intravascular injection.
• Poorly Controlled Hyperthyroidism: Increased sensitivity to catecholamines elevates the risk of
thyroid storm.
• Bronchial Asthma (with Sulfite Sensitivity): Metabisulfite in vasoconstrictor-containing cartridges
may trigger bronchospasm.
• Significant Hepatic Dysfunction (for amide agents like lidocaine, bupivacaine): These are
metabolized in the liver, leading to a risk of accumulation and toxicity.
• Renal Impairment: Delayed excretion poses a risk of drug accumulation with repeated dosing.
Contraindications
of LARelative
Contraindications
Clinical scenarios in which local anesthetics may be employed cautiously, often with dose
adjustments or alternative agents, based on a comprehensive risk-benefit analysis.
• Pregnancy (especially 1st trimester): Prefer Category B agents (e.g., lidocaine) and avoid
unnecessary local anesthetics with vasoconstrictors.
• Psychologically Unstable or Anxious Patients: May exhibit exaggerated responses or
hyperventilation. Consider conscious sedation with local anesthetic or general anesthesia
depending on the procedure.
• Medication Interactions with Vasoconstrictors
⚬ Tricyclic Antidepressants (TCAs): Risk of hypertensive crisis.
⚬ Non-selective Beta-Blockers: Can lead to unopposed alpha stimulation.
⚬ Cocaine abuse within 24 hours: Absolute contraindication for epinephrine.
Contraindications
of LASpecial
Considerations
Not True Contraindications but
Require Caution
• Infection at injection site: acidic pH reduces anesthetic effectiveness → prefer nerve block
• Bleeding disorders or anticoagulant therapy: avoid deep nerve blocks (e.g., PSA, IANB)
• History of malignant hyperthermia: older concern — not a contraindication for amides as per
newer literature
Maximum Recommended
Dose
(MRD)
The Maximum Recommended Dose (MRD) is
defined as the highest quantity of a local
anesthetic agent that can be administered safely
within a single clinical session without eliciting
systemic toxic effects, expressed in mg/kg or mg/lb
of body weight.
This parameter is critical to ensure patient safety
by mitigating the risk of local anesthetic
systemic toxicity (LAST).
MRD Values
MRD Calculation
Formula:
MRD (mg) = weight (kg) × mg/kg
Dosage per Dental
Cartridge (1.8 mL)
MRD Calculation
Calculation of Dosage per milliliter
(mL)
• In pharmacology, a 1% solution denotes 1 gram of drug in 100 mL of
solution.
⚬ = 10mg/ml of solution
• Therefore, to convert any % concentration to mg/mL, multiply the
percentage by 10.
⚬ E.g., 2% = 2 × 10 = 20 mg/mL
MRD Calculation
Calculation of MRD - Example:
• Patient: 60 kg adult
• Agent:
MRD (mg)2%= weight (kg)
Lidocaine with× VC
mg/kg
• MRD: 7.0 mg/kg × 60 = 420 mg
• Dosage of 2% Lidocaine with VC:
⚬ 20 mg = 1 mL of lidocaine
⚬ 1 mg = 1/20 mL
⚬ 420 mg = 420 / 20
￭ =21 mL of Lidocaine with VC
⚠️
⚠️Always
Always round
round down,
down, avoid
avoid exceeding
exceeding total
total
mg limits.
mg limits.
References
• Malamed SF. Handbook of Local Anesthesia. 7th
ed. Elsevier; 2019.
• Balaji SM. Textbook of Oral and Maxillofacial
Surgery. 5th ed. Elsevier; 2020.
• Monheim LM. Local Anesthesia and Pain Control
in Dental Practice. 7th ed. CV Mosby; 1984.
• Goodman & Gilman. The Pharmacological Basis
of Therapeutics. 13th ed. McGraw-Hill
Education; 2018.
• Tripathi KD. Essentials of Medical Pharmacology.
8th ed. Jaypee Brothers Medical Publishers;
2019.
