A. V. Kuzin

Candidate of Medical Sciences, dental surgeon at the Federal State Institution "Central Scientific Research Institute of Dentistry and Maxillofacial Surgery" of the Ministry of Health of the Russian Federation, consultant physician at 3M ESPE on pain management in dentistry

M. V. Stafeeva

dentist-therapist, private practice (Moscow)

V. V. Voronkova

Ph.D., dentist-therapist of the department therapeutic dentistry Clinical and diagnostic center of the State Budgetary Educational Institution of Higher Professional Education “First Moscow State Medical University named after. I. M. Sechenov" of the Ministry of Health of Russia

Often in clinical practice there is a need to use anesthetics short acting. There are many low-volume dental procedures that require pain relief. Long-term use active anesthetics not entirely legal, since the patient leaves the dentist with numbness in a certain area of ​​the oral cavity lasting from 2 to 6 hours.

Taking into account the labor and social load on the patient, the use of short-acting anesthetics is justified, which can reduce the duration of soft tissue numbness to 30-45 minutes. Today in dentistry these requirements are met local anesthetics based on mepivacaine.

Mepivacaine is the only amide anesthetic that can be used without the addition of a vasoconstrictor. Most amide anesthetics (articaine, lidocaine) dilate blood vessels at the injection site, which leads to their rapid absorption into the bloodstream. This shortens their duration of action, so dosage forms anesthetics are available with epinephrine. In the Russian Federation, lidocaine is produced in ampoules without vasoconstrictors, which requires its dilution with epinephrine before use. According to modern standards of pain management in dentistry, the preparation of a local anesthetic solution by staff is a violation of the anesthesia technique. 3% mepivacaine has a less pronounced local vasodilator effect, which allows it to be effectively used to anesthetize teeth and soft tissues of the oral cavity (Table No. 1).

The duration of action of mepivacaine-containing anesthetics (mepivastezin) varies in individual areas of the oral cavity. This is due to some features of its pharmacological action and features of the anatomy of the oral cavity. According to the instructions of the local anesthetic, the duration of anesthesia for the dental pulp is on average 45 minutes, anesthesia for soft tissues - up to 90 minutes. These data were obtained as a result of an experimental study in practically healthy patients during anesthesia of single-rooted teeth mainly on upper jaw. Naturally, such studies do not reflect real clinical conditions, in which the dentist is faced with inflammatory phenomena in tissues, chronic neuropathic pain, individual characteristics patient's anatomy. According to data from domestic scientists, it was found that average duration Dental pulp anesthesia when using 3% mepivacaine is 20-25 minutes, and the duration of soft tissue anesthesia depends on the volume of anesthetic administered and the anesthesia technique (infiltration, conduction) and is 45-60 minutes.

An important issue is the speed of attack. local anesthesia. Thus, when using 3% mepivacaine, the rate of onset of dental pulp anesthesia is 5-7 minutes. Therapeutic dental treatment will be most painless for the patient from the 5th to the 20th minute after anesthesia. Surgery will be painless from the 7th to the 20th minute after local anesthesia.

There are some peculiarities in the anesthesia of certain groups of teeth with 3% mepivacaine. Numerous studies have proven that it is most effective in relieving pain in single-rooted teeth. The incisors of the upper and lower jaws are anesthetized with infiltration anesthesia with 3% mepivacaine in a volume of 0.6 ml. In this case, it is important to take into account the topography of the apexes of the roots of the teeth and, accordingly, the depth of advancement of the carpule needle into the tissue. For anesthesia of canines, premolars and molars of the upper jaw, the authors recommend creating an anesthetic depot of 0.8-1.2 ml. Premolars lower jaw respond well to pain relief with 3% mepivacaine: submental anesthesia is performed in various modifications, where an anesthetic depot of up to 0.8 ml is created. It is important after submental anesthesia to apply digital pressure to the soft tissues above the mental foramen for better diffusion of the anesthetic. Infiltration anesthesia in the area of ​​mandibular molars with 3% mepivacaine is ineffective compared to articaine. Anesthesia of mandibular molars with 3% mepivacaine is advisable only in patients with contraindications to the use of articaine-containing anesthetics with epinephrine: in these cases, mandibular anesthesia (1.7 ml of 3% mepivacaine) must be performed. Mandibular canines are also anesthetized with chin or mandibular anesthesia in patients with the contraindications described above.

As a result of many years of experience clinical application mepivacaine indications were developed and clinical guidelines to its use. Of course, mepivacaine is not an “every day” anesthetic; however, there are a number clinical cases when its use is most appropriate.

Patients with chronic general somatic diseases. First of all, the use of mepivacaine is most justified in patients with cardiovascular pathology and restrictions on the use of a vasoconstrictor. If a low-traumatic intervention lasting less than 20-25 minutes is planned, there are indications for the use of 3% mepivacaine, which does not affect the patient’s hemodynamic parameters (BP, HR). If more is planned long-term treatment or intervention in the area of ​​the molars of the lower jaw, from a clinical point of view, the use of only articaine-containing anesthetics with a vasoconstrictor of 1:200,000 is justified.

Patients with a history of allergies. There is a group of patients bronchial asthma, in whom the use of articaine with a vasoconstrictor is contraindicated due to the risk of developing status asthmaticus due to the preservatives contained in the carpule. Mepivacaine does not contain preservatives (sodium bisulfite) and can therefore be used for short-term interventions in this group of patients. With longer interventions in this group of patients dental treatment It is advisable to carry out in specialized institutions under the guidance of an anesthesiologist. Mepivacaine can be used in patients with multivalent allergies and those allergic to a known anesthetic. Outpatient dental treatment of such patients is carried out after the conclusion of an allergist on the tolerability of the drug. According to clinical experience the authors of this article, the frequency of positive allergy tests for 3% mepivacaine is significantly lower in comparison with other carpule anesthetics.

IN therapeutic dentistry mepivacaine is used in the treatment of uncomplicated caries: enamel caries, dentin caries. It is important to consider that the required duration of anesthesia is limited to the stage of preparation of hard dental tissues. After covering the formed cavity with adhesive material, further restoration will be painless. Accordingly, any planned invasive treatment should not exceed 15 minutes after the onset of anesthesia. Also, when planning treatment, one should take into account the low effectiveness of mepivacaine in anesthesia of canines and molars of the lower jaw with infiltration anesthesia and with intraligamentary anesthesia of the teeth of the lower jaw.

IN surgical dentistry mepivacaine is used for short-term surgical interventions. The greatest effectiveness was found when removing teeth with chronic periodontitis and when removing intact teeth for orthodontic indications. The role of mepivacaine in pain relief during surgical dressings is important. Often, the procedure for removing sutures, changing the wound covering in the tooth socket, and changing the iodoform dressing is painful for patients. The use of long-acting anesthetics is unjustified due to the subsequent long-term numbness of soft tissues, which can lead to self-injury of the surgical site when eating. In these cases, infiltration anesthesia is used in a volume of 0.2-0.4 ml of 3% mepivacaine, and for dressings after extensive surgical interventions (cystectomy, excision of soft tissue formations, removal of an impacted third molar), conduction anesthesia is performed. The use of mepivacaine during outpatient surgical dressings can reduce patient discomfort and stress.

Pediatric dentistry. Short-acting anesthetics have proven themselves well when used in pediatric dentistry. When using mepivacaine, the dosage of this drug should be taken into account when performing local anesthesia in children. Mepivacaine is more toxic to the central nervous system than articaine because it is rapidly absorbed into the bloodstream. Also, the clearance of mepivacaine is higher than the clearance of articaine for several hours. Maximum dosage 3% mepivacaine is 4 mg/kg of body weight for a child over 4 years of age (Table No. 2). However, in pediatric dentistry there are no indications for the use of such high volumes of anesthetic. According to modern safety standards, the dosage of administered 3% mepivacaine should not exceed half the maximum dose for all dental treatment. With this use, cases of local anesthetic overdose (weakness, drowsiness, headaches) in pediatric practice are excluded.

When using mepivacaine, cases of self-injury of the soft tissues of the oral cavity by a child after treatment at the dentist are practically excluded. According to statistics, up to 25-35% of children preschool age the lower lip is injured after treatment of the lower teeth, and in most cases this is associated with the use of anesthetics long acting based on articaine with a vasoconstrictor. Short-acting local anesthetics can be used when sealing dental fissures, treating initial forms caries, removal of temporary teeth. The use of mepivacaine in children with polyvalent allergies and bronchial asthma is especially justified, since the drug does not contain preservatives (EDTA, sodium bisulfite).

Pregnancy and breastfeeding. Mepivacaine can be safely used in pregnant women during routine sanitation of the oral cavity at the dentist according to the indications described above. In most cases, 3% mepivacaine is used for short-term and minimally invasive interventions lasting up to 20 minutes. The second trimester of pregnancy is most favorable for treatment.

Mepivacaine can be used in breastfeeding women and is found in breast milk mother in a concentration that is insignificant for the child. However, the patient is recommended to refrain from feeding the child for 10-12 hours after anesthesia with 3% mepivacaine and for 2 hours after anesthesia with 4% articaine with epinephrine, which completely eliminates the effect of the anesthetic on the child.

conclusions

Thus, mepivacaine-containing anesthetics (Mepivastezin) have found their use in various fields of dentistry. For a certain group of patients, these anesthetics are the only drugs for local anesthesia due to general somatic features. As a short-acting anesthetic, the drug can be well used for minimally invasive short-term interventions.

Table No. 1. Features of the clinical use of 3% mepivacaine (Mepivastezin)

Table No. 2. Dosage of 3% mepivacaine based on patient weight (adult/child)

Weight	Mg	Ml	Carpools
		1.5	0.8
		2.2	1.2
		2.8	1.4
	110	3.6	1.7
	132	4.4	2.4
	154	5.1	2.9
	176	5.9	3.2
	198	6.6	3.6
	220	7.3	4.0
Mepivacaine 3% without vasoconstrictor. Maximum dose 4.4 mg/kg; 3% solution in 1 carpule 1.8 ml (54 mg)

Mepivacaine ( international name Mepivacaine) is a local anesthetic of the amide group, derived from xylidine. Mepivacaine is used in infiltration for peripheral transthoracic anesthesia and for sympathetic, regional and epidural nerve blocks in surgical and dental procedures. It is available commercially with and without adrenaline. Compared to mepivacaine, it produces less vasodilation and has a faster onset and longer duration of action.

Commercially known as: mepivastezin (JEPHARM, Palestine), scandonest (Septodont, France), scandicaine, carbocaine (Caresteam Health, Inc., USA).

Mepivacaine has a faster onset of action and is more long term than lidocaine. Its duration of action is about 2 hours and it is twice as effective as procaine. Used for local anesthesia in dentistry and spinal anesthesia. At a concentration of 3% it is produced without a vasoconstrictor, at 2% with a vasoconstrictor, brand name levonordefrin, concentration 1:20000. The anesthetic is recommended for use in patients for whom anesthetics with a vasoconstrictor are contraindicated.

Mepivacaine in dentistry

Local anesthetic is used in dentistry to perform the following types of anesthesia on the lower and lower extremities:

Mepivacaine in dentistry

Mechanism of action

Like all drugs, mepivacaine causes a reversible block of nerve conduction, reducing the permeability of the nerve membrane to sodium ions (Na+). This reduces the rate of membrane depolarization, thereby increasing the threshold of electrical excitability. The blockage affects all nerve fibers in the following sequence: autonomic, sensory, and motor, with diminishing effects as reverse order. Clinically, loss of nerve function follows the following order: pain, temperature, touch, proprioception, and tone skeletal muscles. For anesthesia to be effective, direct penetration of the nerve membrane is necessary, which is achieved by injecting a local anesthetic solution subcutaneously, intradermally, or submucosally around the nerve trunks or ganglia. For mepivacaine, the degree of motor blockade depends on the concentration and can be summarized as follows:

• 0.5% is effective in blocking small superficial nerves;
• 1% will block sensory and sympathetic conduction without affecting performance motor system;
• 1.5% will provide extensive and often complete blockage of the motor system
• 2% will ensure complete blocking of the motor system by any group of nerves.

Pharmacokinetics

Systemic absorption of mepivacaine depends on the dose, concentration, route of administration, tissue vascularization and degree of vasodilation. The use of mixtures containing vasoconstrictors will counteract the vasodilation produced by mepivacaine. This reduces the rate of absorption, prolongs the duration of action and maintains hemostasis. For dental anesthesia, the onset of action for the upper and lower jaw occurs after 0.5-2 minutes and 1-4 minutes, respectively. lasts for 10-17 minutes, and soft tissue anesthesia lasts about 60-100 minutes after administration of the adult dose. When performing the epidural method of pain relief, mepivacaine has an effect of 7-15 minutes and a duration of approximately 115-150 minutes.

Mepivacaine crosses the placenta by passive diffusion and is distributed throughout all tissues with high concentrations in well-perfused organs such as the liver, lungs, heart and brain. Mepivacaine undergoes rapid metabolism in the liver and is deactivated through hydroxylation and N-demethylation. Three were found in adults inactive metabolite: two are phenols, which are isolated as glucuronide conjugates, and one is 2′, 6′-picloxidine. Approximately 50% of mepivacaine is excreted into the bile as metabolites that enter the enterohepatic circulation and are subsequently excreted. Only 5-10% of mepivacaine is excreted unchanged in the urine. Some metabolism may occur in the lungs.

Newborns may have limited ability to the metabolism of mepivacaine, but they are able to eliminate the unmodified drug. The half-life of mepivacaine is 1.9 to 3.2 hours in adults and 8.7 to 9 hours in newborns.

Local ester anesthetics are metabolized in plasma by the enzyme pseudocholinesterase, and one of the main metabolites is para-aminobenzoic acid, which appears to be responsible for allergic reactions. Anesthetics of the amide group are metabolized in the liver and do not form para-aminobenzoic acid.

Indications for use

For cervical nerve block, blockade brachial plexus, blockade of the intercostal nerve. Adults: 5-40 ml of a 1% solution (50-400 mg) or 5-20 ml of a 2% solution (100-400 mg). Dose increases should not be made more frequently than every 90 minutes.

For anesthesia peripheral nerves and cupping severe pain. Adults: 1-5 ml of a 1-2% solution (10-100 mg) or 1.8 ml of a 3% solution (54 mg). Dose increases should not be made more frequently than every 90 minutes.

For dental anesthesia by infiltration. Adults: 1.8 ml of 3% solution (54 mg). Infiltration should be done slowly with frequent aspirations. In adults, 9 ml (270 mg) of a 3% solution is usually sufficient to cover the entire mouth. The total dose should not exceed 400 mg. Incremental doses should not be administered more frequently than every 90 minutes.
Children: 1.8 ml of 3% solution (54 mg). Infiltration should be done slowly with frequent aspirations. The maximum dose should not exceed 9 ml (270 mg) of a 3% solution. The maximum dose can be calculated using the following formula, based on Clark's rule: Maximum dose (mg) = weight (in pounds) / 150 x 400 mg. 1 pound = 0.45 kilograms.

The dose of local anesthetics differs depending on the anesthetic procedure, the area to be anesthetized, the vascularity of the tissue and the number of nerves blocked, the intensity of the blockade, the required degree of muscle relaxation, the desired duration of anesthesia, individual indications and physical condition patient.

Mepivacaine is predominantly metabolized in the liver. Lower doses of mepivacaine administration may be required in patients with hepatic dysfunction due to prolonged effects and systemic accumulation. Specific dosing recommendations are not available.

Contraindications for use

Local anesthetics should only be prescribed by a physician trained in the diagnosis and treatment of analgesic toxicity and the management of serious emergencies that may result from the administration of a regional anesthetic. Before starting the administration of the drug, it is necessary to ensure the immediate availability of oxygen, equipment for cardiopulmonary resuscitation, appropriate medications, support personnel for the treatment of toxic reactions or emergency situations. Any delay in correct provision emergency care may lead to acidosis, cardiac arrest and possibly death.

Intravenous or intra-arterial administration of mepivacaine should be avoided. Forced intravenous or intra-arterial administration may cause cardiac arrest and require prolonged resuscitation. To avoid intravascular administration of mepivacaine during local anesthetic procedures, aspiration should be performed before local anesthetic administration and after needle changes. During epidural administration, a control dose should be administered first, and the patient's CNS status and cardiovascular toxicity should be monitored, as well as signs of accidental intrathecal administration.

For head and neck anesthesia, including ophthalmic and dental anesthesia, small doses of local anesthetics can cause adverse reactions, similar to the systemic toxicity observed with accidental intravascular injections of higher doses.

When local anesthetics are used for retrobulbar block in ophthalmic surgery, lack of corneal sensation should not be taken as a basis for determining whether the patient is ready for surgery. Lack of corneal sensation usually precedes clinically acceptable akinesia of the external ocular muscles.

Mepivacaine epidural and nerve injections are contraindicated in patients with the following characteristics: infection or inflammation at the injection site, bacteremia, platelet abnormalities, thrombocytopenia<100 000 / мм3, увеличение времени свертывания крови, неконтролируемая коагулопатия и терапия антикоагулянтами. Поясничную анестезию и каудальную анестезию следует использовать с особой осторожностью у пациентов с неврологическими заболеваниями, деформациями позвоночника, сепсисом или тяжелой гипертонией.

Local anesthetics should be used with caution in patients with hypotension, hypovolemia or dehydration, myasthenia gravis, shock, or cardiac disease. Patients with impaired cardiac function, especially AV block, may be less able to compensate for the functional changes associated with prolonged AV conduction (QT interval prolongation) caused by local anesthetics.

Mepivacaine is contraindicated in patients with known hypersensitivity to amide-type local anesthetics. Elderly patients, especially those receiving treatment for hypertension, may be at greater risk of the hypotensive effects of mepivacaine.

No long-term animal studies have been conducted to evaluate carcinogenic and mutagenic potential in fertility settings. There is no human data to suggest that mepivacaine is mutagenic or carcinogenic.

• Contraindicated in patients with hypersensitivity to amide local anesthetics or any other component of the drug formula
• Serious liver disorders: cirrhosis, porphyrin disease. Patients receiving these blocks should have their ventilatory and circulatory systems closely monitored, and recommended doses should not be exceeded in these patients.
• For patients with myasthenia gravis

General precautions

• Patients under anesthesia should delay eating until sensation in the lips, cheeks, and tongue is fully restored.
• In pediatric, elderly and malnourished patients, the dose of anesthetic should be reduced
  High doses of the drug are prohibited for patients with epilepsy
• Use extreme caution in patients with liver disease due to the liver's metabolism of amides - this may precipitate the development of anemia
• When using any type of local anesthetic, oxygen equipment and resuscitative drugs must be available for immediate use.
• Injection into a swollen or infected area should be avoided as it may change the pH and thus alter the effect of the anesthetic.

Mepivacaine during pregnancy and lactation

There is significant transfer of mepivacaine across the maternal placenta, and the ratio between fetal drug concentrations and maternal concentrations is approximately 0.7. Although neonates have a very limited ability to metabolize mepivacaine, they appear to be able to eliminate this drug. The safety of mepivacaine hydrochloride during breastfeeding is unknown. The medicine should be prescribed with caution!

Mepivacaine rapidly crosses the placenta and, when used in epidural, paracervical, caudal, or pudendal anesthesia, may cause maternal, fetal, or neonatal toxicity. Mepivacaine should be used with caution in women who are breastfeeding as it is not known whether mepivacaine is excreted in milk.

Adverse reactions

Like all local anesthetics, mepivacaine can cause significant CNS and cardiovascular toxicity, especially when high serum concentrations are achieved. CNS toxicity occurs at lower doses and at lower plasma concentrations than those associated with cardiac toxicity. CNS-induced toxicity typically presents with stimulation symptoms such as restlessness, anxiety, nervousness, disorientation, confusion, dizziness, blurred vision, nausea/vomiting, tremors, and seizures. Subsequently, depressive symptoms may occur, including drowsiness, unconsciousness, and respiratory depression (which may lead to respiratory arrest).

In some patients, symptoms of CNS toxicity may be mild and short-lived. Seizures can be treated with intravenous benzodiazepines, although this should be done with caution since these agents are also CNS depressants.

The cardiac effects of local anesthetics are due to conduction interference in the myocardium. Cardiac effects are observed at very high doses and usually occur after the onset of CNS toxicity. Adverse cardiovascular effects caused by mepivacaine include myocardial depression, AV block, PR prolongation, QT prolongation, atrial fibrillation, sinus bradycardia, cardiac arrhythmias, hypotension, cardiovascular collapse, and cardiac arrest.

Maternal seizures and cardiovascular collapse may occur following paracervical blockade in early pregnancy (eg, anesthesia for elective abortion) due to rapid systemic absorption.

Cardiovascular side effects from mepivacaine administration should be managed with general physiologic support measures such as oxygen, assisted ventilation, and intravenous fluids.

There may be a burning sensation at the injection site. Pre-existing inflammation or infection increases the risk of developing serious skin side effects. Patients should be monitored for injection site reactions.

Allergic reactions are characterized by rash, hives, swelling, itching, etc. may result from sensitivity to local anesthesia or methipaben, which is used as a preservative in some medications.

During caudal or lumbar epidural nerve blocks, inadvertent penetration of the subarachnoid space may occur.

During labor and delivery, local anesthetics can cause varying degrees of toxicity in the mother, fetus, and neonates. The potential for toxicity is related to the procedure performed, the type and amount of drug used, and the technique of administration. The fetal heart rate will be constantly monitored because fetal bradycardia may occur and may be associated with fetal atherosis. Maternal hypotension may result from regional anesthesia, which may alleviate this problem.

Although the anesthetic does not affect the ability to drive a vehicle, the dentist must decide when the patient can drive a car.

Gross formula

C15H22N2O

Pharmacological group of the substance Mepivacaine

Nosological classification (ICD-10)

CAS code

22801-44-1

Characteristics of the substance Mepivacaine

Amide type anesthetic.

Mepivacaine hydrochloride is a white, odorless, crystalline powder. Soluble in water, resistant to both acid and alkaline hydrolysis.

Pharmacology

pharmachologic effect- local anesthetic.

Being a weak lipophilic base, it passes through the lipid layer of the nerve cell membrane and, transforming into a cationic form, binds to the receptors (residues of S6 transmembrane helical domains) of sodium channels of membranes located at the endings of sensory nerves. Reversibly blocks voltage-gated sodium channels, prevents the flow of sodium ions through the cell membrane, stabilizes the membrane, increases the threshold of electrical stimulation of the nerve, reduces the rate of occurrence of the action potential and reduces its amplitude, and ultimately blocks membrane depolarization, the occurrence and conduction of impulses along nerve fibers.

Causes all types of local anesthesia: terminal, infiltration, conduction. Has a fast and strong effect.

When it enters the systemic circulation (and creates toxic concentrations in the blood), it can have a depressant effect on the central nervous system and myocardium (however, when used in therapeutic doses, changes in conductivity, excitability, automaticity and other functions are minimal).

Dissociation constant (pK a) - 7.6; Solubility in fats is average. The extent of systemic absorption and plasma concentration depend on the dose, route of administration, vascularization of the injection site and the presence or absence of epinephrine in the anesthetic solution. Adding a dilute solution of epinephrine (1:200,000, or 5 mcg/ml) to a mepivacaine solution usually reduces the absorption of mepivacaine and its plasma concentration. Plasma protein binding is high (about 75%). Penetrates through the placenta. Not affected by plasma esterases. Rapidly metabolized in the liver, the main metabolic pathways are hydroxylation and N-demethylation. In adults, 3 metabolites have been identified - two phenolic derivatives (excreted in the form of glucuronides) and an N-demethylated metabolite (2,6"-pipecoloxylide). T1/2 in adults - 1.9-3.2 hours; in newborns - 8.7-9 hours. More than 50% of the dose in the form of metabolites is excreted into bile, then reabsorbed in the intestine (a small percentage is found in feces) and excreted in the urine after 30 hours, incl. unchanged (5-10%). Cumulates in case of liver dysfunction (cirrhosis, hepatitis).

Loss of sensitivity is noted after 3-20 minutes. Anesthesia lasts 45-180 minutes. The time parameters of anesthesia (onset time and duration) depend on the type of anesthesia, the technique used, the concentration of the solution (dose of the drug) and the individual characteristics of the patient. The addition of vasoconstrictor solutions is accompanied by prolongation of anesthesia.

Studies assessing carcinogenicity, mutagenicity, and effects on fertility in animals and humans have not been conducted.

Use of the substance Mepivacaine

Local anesthesia for interventions in the oral cavity (all types), tracheal intubation, broncho- and esophagoscopy, tonsillectomy, etc.

Contraindications

Hypersensitivity, incl. to other amide anesthetics; old age, myasthenia gravis, severe liver dysfunction (including liver cirrhosis), porphyria.

Restrictions on use

Pregnancy, breastfeeding.

Use during pregnancy and breastfeeding

During pregnancy, it is possible if the expected effect of therapy exceeds the potential risk to the fetus (can cause narrowing of the uterine artery and fetal hypoxia). With caution during breastfeeding (no data on penetration into breast milk).

Side effects of the substance Mepivacaine

From the nervous system and sensory organs: agitation and/or depression, headache, ringing in the ears, weakness; impaired speech, swallowing, vision; convulsions, coma.

From the cardiovascular system and blood (hematopoiesis, hemostasis): hypotension (or sometimes hypertension), bradycardia, ventricular arrhythmia, possible cardiac arrest.

Allergic reactions: sneezing, urticaria, pruritus, erythema, chills, fever, angioedema.

Others: depression of the respiratory center, nausea, vomiting.

Interaction

Beta-blockers, calcium channel blockers, and antiarrhythmic drugs enhance the inhibitory effect on myocardial conductivity and contractility.

Overdose

Symptoms: hypotension, arrhythmia, increased muscle tone, loss of consciousness, convulsions, hypoxia, hypercapnia, respiratory and metabolic acidosis, dyspnea, apnea, cardiac arrest.

Treatment: hyperventilation, maintenance of adequate oxygenation, assisted breathing, control of convulsions and seizures

(prescription of thiopental 50-100 mg IV or diazepam 5-10 mg IV), normalization of blood circulation, correction of acidosis.

Catad_pgroup Local anesthetics

Mepivacaine-Binergy - instructions for use

Registration number:

LP-005178

Trade name:

Mepivacaine-Binergy

International nonproprietary name:

mepivacaine

Dosage form:

injection

Compound

1 ml of the drug contains:
active substance: mepivacaine hydrochloride – 30 mg;
Excipients: sodium chloride, water for injection.

Description

Transparent colorless solution

Pharmacotherapeutic group

Local anesthetic

ATX Code:

Pharmacological properties

Pharmacodynamics
Mepivacaine is an amide-type local anesthetic. When administered by injection near sensory nerve endings or nerve fibers, mepivacaine reversibly blocks voltage-gated sodium channels, preventing the generation of impulses at sensory nerve endings and the transmission of pain impulses in the nervous system. Mepivacaine is lipophilic with a pKa value of 7.6. Mepivacaine penetrates the nerve membrane in the basic form, then, after reprotonation, exerts its pharmacological effect in the ionized form. The ratio of these forms of mepivacaine is determined by the pH value of the tissues in the anesthetized area. At low tissue pH values, such as in inflamed tissue, the basic form of mepivacaine is present in small quantities and therefore anesthesia may be insufficient.
Unlike most local anesthetics, which have vasodilating properties, mepivacaine does not have a pronounced effect on blood vessels and can be used in dentistry without a vasoconstrictor.
The time parameters of anesthesia (onset time and duration) depend on the type of anesthesia, the technique used, the concentration of the solution (dose of the drug) and the individual characteristics of the patient.
With peripheral nerve blockade, the effect of the drug occurs within 2-3 minutes.
The average duration of action for pulp anesthesia is 20-40 minutes, and for soft tissue anesthesia - 2-3 hours.
The duration of motor blockade does not exceed the duration of anesthesia.

Pharmacokinetics
Suction, distribution
When administered into the tissues of the maxillofacial area through conduction or infiltration anesthesia, the maximum concentration of mepivacaine in the blood plasma is achieved approximately 30-60 minutes after the injection. The duration of action is determined by the rate of diffusion from tissues into the bloodstream. The distribution coefficient is 0.8. Plasma protein binding is 69-78% (mainly with alpha-1-acid glycoprotein).
The degree of bioavailability reaches 100% in the area of ​​action.
Metabolism
Mepivacaine is rapidly metabolized in the liver (undergoing hydrolysis by microsomal enzymes) by hydroxylation and dealkylation to m-hydroxymepivacaine, p-hydroxymepivacaine, pipecolylxylidine, and only 5-10% is excreted unchanged by the kidneys.
Subject to hepatic-intestinal recirculation.
Removal
It is excreted by the kidneys, mainly in the form of metabolites. Metabolites are mainly excreted from the body with bile. The half-life (T 1/2) is long and ranges from 2 to 3 hours. The half-life of mepivacaine from blood plasma is increased in patients with impaired hepatic function and/or in the presence of uremia. In case of liver pathology (cirrhosis, hepatitis), accumulation of mepivacaine is possible.

Indications for use

Infiltration, conduction, intraligamentary, intraosseous and intrapulpal anesthesia for surgical and other painful dental interventions.
The drug does not contain a vasoconstrictor component, which allows it to be used in patients with diseases of the cardiovascular system, diabetes mellitus, and angle-closure glaucoma.

Contraindications

• hypersensitivity to mepivacaine (including other local anesthetic drugs of the amide group) or other excipients included in the drug;
• severe liver diseases: cirrhosis, hereditary or acquired porphyria;
• myasthenia gravis;
• children under 4 years of age (body weight less than 20 kg);
• heart rhythm and conduction disorders;
• acute decompensated heart failure;
• arterial hypotension;
• intravascular administration (before administering the drug, an aspiration test must be performed, see section “Special Instructions”).

Carefully

• conditions accompanied by decreased hepatic blood flow (for example, chronic heart failure, diabetes mellitus, liver disease);
• progression of cardiovascular failure;
• inflammatory diseases or infection of the injection site;
• pseudocholinesterase deficiency;
• renal failure;
• hyperkalemia;
• acidosis;
• old age (over 65 years);
• atherosclerosis;
• vascular embolism;
• diabetic polyneuropathy.

Use during pregnancy and breastfeeding

Pregnancy
During pregnancy, local anesthesia is considered the safest method for relieving pain during dental procedures. The drug does not affect the course of pregnancy, however, due to the fact that mepivacaine can cross the placenta, it is necessary to evaluate the benefit to the mother and the risk to the fetus, especially in the first trimester of pregnancy.
Breastfeeding period
Local anesthetics, including mepivacaine, are excreted in small amounts into breast milk. With a single use of the drug, a negative effect on the child is unlikely. Breastfeeding is not recommended within 10 hours after using the drug.

Directions for use and doses

The amount of solution and the total dose depend on the type of anesthesia and the nature of the surgical intervention or manipulation.
The rate of administration should not exceed 1 ml of the drug in 1 minute.
Aspiration control should always be performed to avoid intravenous administration.
Use the smallest dose of the drug that provides sufficient anesthesia.
The average single dose is 1.8 ml (1 cartridge).
Cartridges that have already been opened should not be used to treat other patients. Cartridges with unused remainder of the drug must be disposed of.
Adults
The recommended maximum single dose of mepivacaine hydrochloride is 300 mg (4.4 mg/kg body weight), which corresponds to 10 ml of the drug (about 5.5 cartridges).
Children over 4 years old (weighing more than 20 kg)
The amount of the drug depends on age, body weight and the nature of the surgical intervention. The average dose is 0.75 mg/kg body weight (0.025 ml of drug/kg body weight).
The maximum dose of mepivacaine is 3 mg/kg body weight, which corresponds to 0.1 ml of drug/kg body weight.

Body weight, kg	Mepivacaine dose, mg	Drug volume, ml	Number of drug cartridges (1.8 ml each)
20	60	2	1,1
30	90	3	1,7
40	120	4	2,2
50	150	5	2,8

Special patient groups
In elderly people, the concentration of the drug in the blood plasma may increase due to a slowdown in metabolism. In this group of patients, it is necessary to use the minimum dose that provides sufficient anesthesia.
In patients with renal or hepatic insufficiency, as well as in patients with hypoxia, hyperkalemia or metabolic acidosis, it is also necessary to use the minimum dose that provides sufficient anesthesia.
In patients with diseases such as vascular embolism, atherosclerosis or diabetic polyneuropathy, it is necessary to reduce the dose of the drug by a third.

Side effect

Possible side effects when using the drug Mepivacaine-Binergia are similar to the side effects that occur when taking amide-type local anesthetics. The most common disorders are the nervous system and the cardiovascular system. Serious side effects are systemic.
Side effects are grouped by systems and organs in accordance with the MedDRA dictionary and the WHO classification of the incidence of adverse reactions: very often (≥1/10), often (≥1/100 to<1/10), нечасто (≥1/1000 до <1/100), редко (≥1/10000 до <1/1000), очень редко (<1 /10000), частота неизвестна (частота не может быть определена на основе имеющихся данных).

System-organ class	Frequency of development	Adverse events
Blood and lymphatic system disorders	Rarely	- methemoglobinemia
Immune system disorders	Rarely	- anaphylactic and anaphylactoid reactions; - angioedema (including swelling of the tongue, mouth, lips, throat and periorbital edema); - urticaria; - skin itching; - rash, erythema
Nervous system disorders	Rarely	1. Effect on the central nervous system (CNS) Due to the increased concentration of anesthetic in the blood entering the brain, a load on the central nervous system and an impact on the regulatory centers of the brain and cranial nerves are possible. Associated side effects include agitation or depression, which are dose-dependent and are accompanied by the following symptoms: - anxiety (including nervousness, agitation, anxiety); - confusion; - euphoria; - numbness of the lips and tongue, paresthesia of the oral cavity; - drowsiness, yawning; - speech disorder (dysarthria, incoherent speech, logorrhea); - dizziness (including numbness, vertigo, imbalance); - headache; - nystagmus; - tinnitus, hyperacusis; - blurred vision, diplopia, miosis The above symptoms should not be considered as symptoms of neurosis. The following side effects are also possible: - blurred vision; - tremor; - muscle cramps These effects are symptoms of the following conditions: - loss of consciousness; - convulsions (including generalized) Convulsions may be accompanied by central nervous system depression, coma, hypoxia and hypercapnia, which can lead to respiratory depression and respiratory arrest. Symptoms of agitation are temporary, but symptoms of depression (such as drowsiness) may lead to unconsciousness or respiratory failure. 2. Effects on the peripheral nervous system (PNS) The effect on the PNS is associated with increased plasma concentrations of the anesthetic. Anesthetic molecules can penetrate from the systemic circulation into the synaptic cleft and have a negative effect on the heart, blood vessels and gastrointestinal tract. 3. Direct local/local effect on efferent neurons or preganglionic neurons in the submandibular region or postganglionic neurons - paresthesia of the oral cavity, lips, tongue, gums, etc.; - loss of sensitivity in the oral cavity (lips, tongue, etc.); - decreased sensitivity of the mouth, lips, tongue, gums, etc.; - dysesthesia, including fever or chills, dysgeusia (including metallic taste); - local muscle cramps; - local/local hyperemia; - local/local pallor 4. Impact on reflexogenic zones Local anesthetics can cause vomiting and the vasovagal reflex, accompanied by the following side effects: - vasodilation; - mydriasis; - pallor; - nausea, vomiting; - hypersalivation; - perspiration
Heart disorders	Rarely	Cardiac toxicity may develop, accompanied by the following symptoms: - cardiac arrest; - cardiac conduction disturbance (atrioventricular block); - arrhythmia (ventricular extrasystole and ventricular fibrillation); - cardiovascular disorder; - disorder of the cardiovascular system; - myocardial depression; - tachycardia, bradycardia
Vascular disorders	Rarely	- vascular collapse; - hypotension; - vasodilation
Respiratory, thoracic and mediastinal disorders	Frequency unknown	- respiratory depression (from bradypnea to respiratory arrest)
Gastrointestinal disorders	Frequency unknown	- swelling of the tongue, lips, gums; - nausea, vomiting; - gum ulceration, gingivitis
General and administration site disorders	Frequency unknown	- necrosis at the injection site; - swelling in the head and neck area

Overdose

Overdose is possible due to unintentional intravascular administration of the drug or as a result of extremely rapid absorption of the drug. The critical threshold dose is a concentration of 5-6 mcg of mepivacaine hydrochloride per 1 ml of blood plasma.
Symptoms
From the central nervous system
Mild intoxication – paresthesia and numbness of the mouth, tinnitus, “metallic” taste in the mouth, fear, anxiety, tremor, muscle twitching, vomiting, disorientation.
Moderate intoxication – dizziness, nausea, vomiting, speech disorder, stupor, drowsiness, confusion, tremor, choreiform movements, tonic-clonic convulsions, dilated pupils, rapid breathing.
Severe intoxication - vomiting (risk of suffocation), sphincter paralysis, loss of muscle tone, lack of reaction and akinesia (stupor), irregular breathing, respiratory arrest, coma, death.
From the heart and blood vessels
Mild intoxication – increased blood pressure, rapid heartbeat, rapid breathing.
Moderate intoxication – rapid heartbeat, arrhythmia, hypoxia, pallor. Severe intoxication - severe hypoxia, cardiac arrhythmia (bradycardia, decreased blood pressure, primary heart failure, ventricular fibrillation, asystole).
Treatment
When the first signs of overdose appear, it is necessary to immediately stop administering the drug, and also provide support for respiratory function, if possible with the use of oxygen, monitoring pulse and blood pressure.
If breathing is impaired - oxygen, endotracheal intubation, artificial ventilation (central analeptics are contraindicated).
In case of hypertension, it is necessary to elevate the patient's upper body, and if necessary, administer nifedipine sublingually.
In case of hypotension, it is necessary to bring the patient’s body position to a horizontal position, and, if necessary, intravascular administration of an electrolyte solution and vasoconstrictor drugs. If necessary, the volume of circulating blood is replaced (for example, with crystalloid solutions).
For bradycardia, atropine (0.5 to 1 mg) is administered intravenously.
In case of convulsions, it is necessary to protect the patient from collateral damage; if necessary, diazepam is administered intravenously (5 to 10 mg). For prolonged convulsions, sodium thiopental (250 mg) and a short-acting muscle relaxant are administered; after intubation, artificial ventilation of the lungs with oxygen is performed.
In case of severe circulatory disorders and shock - intravenous infusion of solutions of electrolytes and plasma substitutes, glucocorticosteroids, albumin.
For severe tachycardia and tachyarrhythmia, use intravenous beta-blockers (selective).
If the heart stops, cardiopulmonary resuscitation must be performed immediately.
When using local anesthetics, it is necessary to provide access to a ventilator, drugs that increase blood pressure, atropine, and anticonvulsants.

Interaction with other drugs

Prescription while taking monoamine oxidase inhibitors (MAO) (furazolidone, procarbazine, selegiline) increases the risk of lowering blood pressure.
Vasoconstrictors (epinephrine, methoxamine, phenylephrine) prolong the local anesthetic effect of mepivacaine.
Mepivacaine enhances the depressant effect on the central nervous system caused by other drugs. When used simultaneously with sedatives, a reduction in the dose of mepivacaine is required.
Anticoagulants (ardeparin sodium, dalteparin, enoxaparin, warfarin) and low molecular weight heparin preparations increase the risk of bleeding.
When treating the mepivacaine injection site with disinfectant solutions containing heavy metals, the risk of developing a local reaction in the form of pain and swelling increases.
Strengthens and prolongs the effect of muscle relaxants.
When prescribed with narcotic analgesics, an additive inhibitory effect on the central nervous system develops.
There is antagonism with antimyasthenic drugs in their effect on skeletal muscles, especially when used in high doses, which requires additional correction of the treatment of myasthenia gravis.
Cholinesterase inhibitors (antimyasthenic drugs, cyclophosphamide, thiotepa) reduce the metabolism of mepivacaine.
When used simultaneously with H2-histamine receptor blockers (cimetidine), the level of mepivacaine in the blood serum may increase.
When used simultaneously with antiarrhythmic drugs (tocainide, sympatholytics, digitalis preparations), side effects may increase.

special instructions

It is necessary to discontinue MAO inhibitors 10 days before the planned administration of a local anesthetic.
Use only in a medical facility.
After opening the ampoule, immediate use of the contents is recommended.
The drug must be administered slowly and continuously. When using the drug, it is necessary to monitor the patient's blood pressure, pulse and pupil diameter.
Before using the drug, it is necessary to ensure access to resuscitation equipment.
Patients receiving anticoagulant treatment have an increased risk of bleeding.
The anesthetic effect of the drug may be reduced when administered into an inflamed or infected area.
When using the drug, unintentional injury to the lips, cheeks, mucous membrane and tongue is possible, especially in children, due to decreased sensitivity.
The patient should be warned that eating is possible only after sensitivity has been restored.
Before administering the drug, aspiration control should always be performed to avoid intravascular administration.
Regional and local anesthesia should be administered by experienced professionals in an appropriately equipped facility with the equipment and medications needed for cardiac monitoring and resuscitation readily available for immediate use. Personnel performing anesthesia should be qualified and trained in anesthesia techniques and should be familiar with the diagnosis and treatment of systemic toxicities, adverse events and reactions, and other complications.
1 ml of the drug contains 0.05 mmol (1.18 mg) sodium.

Impact on the ability to drive vehicles and machinery

The drug has a slight effect on the ability to drive vehicles and machinery. During the treatment period, care must be taken when driving vehicles and engaging in other potentially hazardous activities that require increased concentration and speed of psychomotor reactions.

Release form

Solution for injection 30 mg/ml.
1.7 ml, 1.8 ml of the drug in cartridges made of transparent colorless glass of the 1st hydrolytic class, sealed on one side with plungers made of elastomeric material, and on the other side with combined caps for dental cartridges for local anesthesia, consisting of a disk of elastomeric material and anodized aluminum cap.
10 cartridges each in a blister plastic package (pallet) or in a blister pack; or in an insert for fixing cartridges.
1.5, 10 contour plastic packages (pallets) or contour cell packaging or inserts with cartridges along with instructions for use in a cardboard pack.
Two protective labels with the company logo are glued onto the pack of cartridges (first opening control).
2 ml of the drug in ampoules made of transparent colorless glass of the 1st hydrolytic class or neutral glass NS-3.
5 ampoules in contour plastic packaging (pallet).
1 or 2 contour plastic packages (pallets) with ampoules along with instructions for use and an ampoule knife or ampoule scarifier in a cardboard pack.
When using ampoules with a colored break point and a notch or a colored break ring, do not insert an ampoule knife or an ampoule scarifier.

Storage conditions

In a place protected from light at a temperature not exceeding 25 ° C. Do not freeze.
Keep out of the reach of children.

Best before date

5 years
Do not use after the expiration date indicated on the package.

Vacation conditions

Dispensed by prescription.

Legal entity in whose name the registration certificate was issued / Organization receiving claims:

CJSC "Binergy", Russia, 143910, Moscow region, Balashikha, st. Krupeshina, 1.

Manufacturer and production address:

FKP "Armavir Biofactory", Russia, 352212, Krasnodar region, Novokubansky district, Progress village, st. Mechnikova, 11.

A. V. Kuzin

Candidate of Medical Sciences, dental surgeon at the Federal State Institution "Central Scientific Research Institute of Dentistry and Maxillofacial Surgery" of the Ministry of Health of the Russian Federation, consultant physician at 3M ESPE on pain management in dentistry

M. V. Stafeeva

dentist-therapist, private practice (Moscow)

V. V. Voronkova

Candidate of Medical Sciences, Dentist-Therapist, Department of Therapeutic Dentistry, Clinical Diagnostic Center, First Moscow State Medical University named after. I. M. Sechenov" of the Ministry of Health of Russia

Often in clinical practice there is a need to use short-acting anesthetics. There are many low-volume dental procedures that require pain relief. The use of long-acting anesthetics is not entirely legal, since the patient leaves the dentist with numbness in a certain area of ​​the oral cavity lasting from 2 to 6 hours.

Taking into account the labor and social load on the patient, the use of short-acting anesthetics is justified, which can reduce the duration of soft tissue numbness to 30-45 minutes. Today in dentistry, local anesthetics based on mepivacaine meet these requirements.

Mepivacaine is the only amide anesthetic that can be used without the addition of a vasoconstrictor. Most amide anesthetics (articaine, lidocaine) dilate the blood vessels at the injection site, which leads to their rapid absorption into the bloodstream. This shortens the duration of their action, which is why dosage forms of anesthetics are available with epinephrine. In the Russian Federation, lidocaine is produced in ampoules without vasoconstrictors, which requires its dilution with epinephrine before use. According to modern standards of pain management in dentistry, the preparation of a local anesthetic solution by staff is a violation of the anesthesia technique. 3% mepivacaine has a less pronounced local vasodilator effect, which allows it to be effectively used to anesthetize teeth and soft tissues of the oral cavity (Table No. 1).

The duration of action of mepivacaine-containing anesthetics (mepivastezin) varies in individual areas of the oral cavity. This is due to some features of its pharmacological action and features of the anatomy of the oral cavity. According to the instructions of the local anesthetic, the duration of anesthesia for the dental pulp is on average 45 minutes, anesthesia for soft tissues - up to 90 minutes. These data were obtained as a result of an experimental study in practically healthy patients during anesthesia of single-rooted teeth, mainly in the upper jaw. Naturally, such studies do not reflect real clinical conditions in which a dentist is faced with inflammatory phenomena in tissues, chronic neuropathic pain, and the individual characteristics of the patient’s anatomy. According to domestic scientists, it was found that the average duration of dental pulp anesthesia when using 3% mepivacaine is 20-25 minutes, and the duration of soft tissue anesthesia depends on the volume of anesthetic administered and the anesthesia technique (infiltration, conduction) and is 45-60 min.

An important issue is the speed of onset of local anesthesia. Thus, when using 3% mepivacaine, the rate of onset of dental pulp anesthesia is 5-7 minutes. Therapeutic dental treatment will be most painless for the patient from the 5th to the 20th minute after anesthesia. Surgical treatment will be painless from the 7th to the 20th minute after local anesthesia.

There are some peculiarities in the anesthesia of certain groups of teeth with 3% mepivacaine. Numerous studies have proven that it is most effective in relieving pain in single-rooted teeth. The incisors of the upper and lower jaws are anesthetized with infiltration anesthesia with 3% mepivacaine in a volume of 0.6 ml. In this case, it is important to take into account the topography of the apexes of the roots of the teeth and, accordingly, the depth of advancement of the carpule needle into the tissue. For anesthesia of canines, premolars and molars of the upper jaw, the authors recommend creating an anesthetic depot of 0.8-1.2 ml. Mandibular premolars respond well to anesthesia with 3% mepivacaine: submental anesthesia is performed in various modifications, where an anesthetic depot of up to 0.8 ml is created. It is important after submental anesthesia to apply digital pressure to the soft tissues above the mental foramen for better diffusion of the anesthetic. Infiltration anesthesia in the area of ​​mandibular molars with 3% mepivacaine is ineffective compared to articaine. Anesthesia of mandibular molars with 3% mepivacaine is advisable only in patients with contraindications to the use of articaine-containing anesthetics with epinephrine: in these cases, mandibular anesthesia (1.7 ml of 3% mepivacaine) must be performed. Mandibular canines are also anesthetized with chin or mandibular anesthesia in patients with the contraindications described above.

As a result of many years of experience in the clinical use of mepivacaine, indications and clinical recommendations for its use have been developed. Of course, mepivacaine is not an “every day” anesthetic; however, there are a number of clinical cases when its use is most appropriate.

Patients with chronic general somatic diseases. First of all, the use of mepivacaine is most justified in patients with cardiovascular pathology and restrictions on the use of a vasoconstrictor. If a low-traumatic intervention lasting less than 20-25 minutes is planned, there are indications for the use of 3% mepivacaine, which does not affect the patient’s hemodynamic parameters (BP, HR). If longer-term treatment or intervention is planned in the area of ​​the mandibular molars, from a clinical point of view, the use of only articaine-containing anesthetics with a vasoconstrictor of 1:200,000 is justified.

Patients with a history of allergies. There is a group of patients with bronchial asthma in whom the use of articaine with a vasoconstrictor is contraindicated due to the risk of developing status asthmaticus due to the preservatives contained in the carpule. Mepivacaine does not contain preservatives (sodium bisulfite) and can therefore be used for short-term interventions in this group of patients. For longer interventions in this group of patients, it is advisable to carry out dental treatment in specialized institutions under the guidance of an anesthesiologist. Mepivacaine can be used in patients with multivalent allergies and those allergic to a known anesthetic. Outpatient dental treatment of such patients is carried out after the conclusion of an allergist on the tolerability of the drug. According to the clinical experience of the authors of this article, the frequency of positive allergy tests for 3% mepivacaine is significantly lower in comparison with other carpulal anesthetics.

IN therapeutic dentistry mepivacaine is used in the treatment of uncomplicated caries: enamel caries, dentin caries. It is important to consider that the required duration of anesthesia is limited to the stage of preparation of hard dental tissues. After covering the formed cavity with adhesive material, further restoration will be painless. Accordingly, any planned invasive treatment should not exceed 15 minutes after the onset of anesthesia. Also, when planning treatment, one should take into account the low effectiveness of mepivacaine in anesthesia of canines and molars of the lower jaw with infiltration anesthesia and with intraligamentary anesthesia of the teeth of the lower jaw.

IN surgical dentistry mepivacaine is used for short-term surgical interventions. The greatest effectiveness was found when removing teeth with chronic periodontitis and when removing intact teeth for orthodontic indications. The role of mepivacaine in pain relief during surgical dressings is important. Often, the procedure for removing sutures, changing the wound covering in the tooth socket, and changing the iodoform dressing is painful for patients. The use of long-acting anesthetics is unjustified due to the subsequent long-term numbness of soft tissues, which can lead to self-injury of the surgical site when eating. In these cases, infiltration anesthesia is used in a volume of 0.2-0.4 ml of 3% mepivacaine, and for dressings after extensive surgical interventions (cystectomy, excision of soft tissue formations, removal of an impacted third molar), conduction anesthesia is performed. The use of mepivacaine during outpatient surgical dressings can reduce patient discomfort and stress.

Pediatric dentistry. Short-acting anesthetics have proven themselves well when used in pediatric dentistry. When using mepivacaine, the dosage of this drug should be taken into account when performing local anesthesia in children. Mepivacaine is more toxic to the central nervous system than articaine because it is rapidly absorbed into the bloodstream. Also, the clearance of mepivacaine is higher than the clearance of articaine for several hours. The maximum dosage of 3% mepivacaine is 4 mg/kg of body weight for a child over 4 years of age (Table No. 2). However, in pediatric dentistry there are no indications for the use of such high volumes of anesthetic. According to modern safety standards, the dosage of administered 3% mepivacaine should not exceed half the maximum dose for all dental treatment. With this use, cases of local anesthetic overdose (weakness, drowsiness, headaches) in pediatric practice are excluded.

When using mepivacaine, cases of self-injury of the soft tissues of the oral cavity by a child after treatment at the dentist are practically excluded. According to statistics, up to 25-35% of preschool children injure the lower lip after treatment of the lower teeth, and in most cases this is associated with the use of long-acting anesthetics based on articaine with a vasoconstrictor. Short-acting local anesthetics can be used when sealing dental fissures, treating initial forms of caries, and removing temporary teeth. The use of mepivacaine in children with polyvalent allergies and bronchial asthma is especially justified, since the drug does not contain preservatives (EDTA, sodium bisulfite).

Pregnancy and breastfeeding. Mepivacaine can be safely used in pregnant women during routine sanitation of the oral cavity at the dentist according to the indications described above. In most cases, 3% mepivacaine is used for short-term and minimally invasive interventions lasting up to 20 minutes. The second trimester of pregnancy is most favorable for treatment.

Mepivacaine can be used in breastfeeding women; it is found in mother's breast milk in concentrations that are insignificant for the baby. However, the patient is recommended to refrain from feeding the child for 10-12 hours after anesthesia with 3% mepivacaine and for 2 hours after anesthesia with 4% articaine with epinephrine, which completely eliminates the effect of the anesthetic on the child.

conclusions

Thus, mepivacaine-containing anesthetics (Mepivastezin) have found their use in various fields of dentistry. For a certain group of patients, these anesthetics are the only drugs for local anesthesia due to general somatic features. As a short-acting anesthetic, the drug can be well used for minimally invasive short-term interventions.

Table No. 1. Features of the clinical use of 3% mepivacaine (Mepivastezin)

Table No. 2. Dosage of 3% mepivacaine based on patient weight (adult/child)

Weight	Mg	Ml	Carpools
		1.5	0.8
		2.2	1.2
		2.8	1.4
	110	3.6	1.7
	132	4.4	2.4
	154	5.1	2.9
	176	5.9	3.2
	198	6.6	3.6
	220	7.3	4.0
Mepivacaine 3% without vasoconstrictor. Maximum dose 4.4 mg/kg; 3% solution in 1 carpule 1.8 ml (54 mg)