Management of Local Anaesthesia in Endodontics
Management of Local Anaesthesia in Endodontics
Halton-Peel Dental AssociationAndrew Moncarz
BSc, DDS, Dip. An, MSc, FRCD(C)
March 22, 2007
Halton-Peel Dental AssociationAndrew Moncarz
BSc, DDS, Dip. An, MSc, FRCD(C)
March 22, 2007
Objectives
Review of: Reported rates of profound anaesthesia Anatomical variations Maximum doses of local anaesthetics Pulpal inflammation as a complicating
factor Adjunctive strategies for profound
mandibular LA
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Effectiveness of Conventional IANB as
measured by EPT
Childers et al. 1997
lido 2% 1:100K
63%
Clark et al. 1999lido 2% 1:100K
73%
Dunbar et al. 1996
lido 2% 1:100K
43%
Guglielmo et al. 1999
mepiv 2% 1:20K
80%
Reitz et al. 1998lido 2% 1:100K
71%
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Always use a long 25 gauge needle (the red one) 2 reasons:
1. Less deflection 2. Less false negative aspiration
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Ultrasound Guidance Hannan et al. 1999: Repeated-measures design 40 subjects injected twice at separate
appointments—once with landmarks, once with ultrasound guidance
EPT after profound lip numbness reported Anaesthetic success 38%-92%, no
difference between the techniques Conclusion: accuracy of needle placement
is not the primary reason for failure of IANB
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Berns et al. 1962: injected radiopaque material into pterygomandibular space
Spread is unpredictable Suggestion: inject more LA
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Decrease in the pH locally Can influence the amount of LA
available in the lipophilic form to diffuse across the nerve membrane
Result is less drug interference of sodium channels
Less likely to influence mandibular block anaesthesia
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Pulpal Inflammation
Causes activation and sensitization of peripheral nociceptors
Causes sprouting of nerve terminals in the pulp
Causes expression of different sodium channels: TTX-resistant class of sodium channels are 4 times as resistant to blockade by lidocaine and their expression is doubled in the presence of PGE2
Effectiveness of Conventional IANB: Irreversible Pulpitis
Reisman et al.1997
1.8 mL lido 2% 1:100K epi
25%
Nusstein et al. 1998
1.8 mL lido 2% 1:100K epi
19%
Cohen et al. 2000
1.8 mL lido 2%1:100K epi
50%
Claffey et al. 2004
1.8 mL lido 2% 1:100K epi 23%
100% lip anaesthesia
Adjunctive Strategies
Additional Anaesthetic PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
Retest using the CC
Adjunctive Strategies
Additional Anaesthetic Higher injection Gow Gates Akinosi Nerve to mylohyoid
PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
Maximum Doses LA
% means g/dL Example:
1% = 1 g/dL 1% = 10g/L 1% = 10 mg/mL
Therefore: 2% = 20 mg/mL
Maximum Doses LA
A cartridge contains 1.8 mL Therefore a cartridge of 2% local
anaesthetic contains 20 mg/mL X 1.8 mL = 36 mg of local anaesthetic
Maximum Doses LA
How much LA can you give? 193 lb 33 yo male Lidocaine 2% 1:100K Articaine 4% 1:200K
2.2 lbs = 1 kg 193 lbs = 88 kg
Maximum Doses LA
Lidocaine 2% Max dose = 7
mg/kg 7mg/kg X 88=616
mg 36 mg/1.8 mL 616mg/36mg/
cart.= 17 cartridges **
Articaine 4% Max dose 7 mg/kg 7 X 88 = 616 mg 72 mg/1.8mL 616 mg/72 mg/cart.
= 9 cartridges
Maximum Doses Epi
% = 1/100 = g/dL Therefore:
1/100 = 1% = 1g/dL = 10 mg/mL 1/1000 = 0.1% = 0.1 g/dL = 1 mg/mL 1/10000 = 0.01% = 0.01 g/dL = 0.1 mg/mL 1/100000 = 0.001% = 0.001 g/dL = 0.01mg/mL
A cartridge contains 1.8 mL Therefore a cartridge of 1:100 000 epi
contains 0.01 mg/mL X 1.8 mL = 0.018 mg(or about 0.02 mg)
Maximum Doses LA Lidocaine 2% Max dose = 7 mg/kg 7mg/kg X 88=616
mg 36 mg/1.8 mL 616mg/36mg/cart.= 17 cartridges ** 10-11 cartridges (epi)
Articaine 4% Max dose 7 mg/kg 7 X 88 = 616 mg 72 mg/1.8mL 616 mg/72 mg/cart.
= 9 cartridges
Pregnant Patients
Which Local Anaesthetic to use?
Articaine 4% 1:200 000 epi Lidocaine 2% 1:100 000 epi Mepivacaine 2% 1:20 000 levo Mepivacaine 3% plain
FDA categories (based on risk of fetal injury)
A: controlled studies in humans—no risk to fetus demonstrated
B: animal studies show no risk, no human studies; or animal studies have shown a risk but human studies have shown no risk
C: animal studies show risk, no human studies; or no animal or human studies
Pregnant Patients
Which Local Anaesthetic to use?
Articaine 4% 1:200 000 FDA category C Lidocaine 2% 1:100 000 FDA category B Mepivacaine 2% 1:20 000 FDA
category C Mepivacaine 3% plain FDA category C
Advantages of Injecting “Higher”
Failure to achieve profound local anaesthesia attributed to being “too low” and “too far forward”
Injecting superiorly and more distally may block accessory innervation
3 nodes of Ranvier may not be true
Gow-Gates Technique
Landmarks: Corner of the mouth (contralateral side) Tragus of the ear Disto palatal cusp of the maxillary
second molar AIMING FOR THE NECK OF THE CONDYLE
Efficacy of the Gow-Gates Technique
Author Year GG (%) IANB (%)
Watson and Gow-Gates
1976 98.4 85.4
Gow-Gates and Watson
1977 96.2 85.5
Levy 1981 96 65
Malamed 1981 97.5
Montagnese et al. 1984 35 38
Akinosi Technique
Closed-mouth technique Does not rely on a hard-tissue
landmark Parallel to occlusal plane, height of
the mucogingival junction Advanced until hub is level with distal
surface of maxillary second molar Delayed onset of anaesthesia
Akinosi Technique
Martinez Gonzalez et al. 2003 Pain to puncture less with Akinosi Onset slower 17.8% failure vs. 10.7% IAB/LB
BUT-incomplete LB considered failure
Cruz et al. 1994 Gow Gates more effective, but Akinosi
most acceptable to patients
Nerve to Mylohyoid
Deposit ¼ cartridge of LA on lingual surface of tooth in alveolar mucosa
Goal is to bathe the nerve as branches of it enter the lingual surface of the mandible
Adjunctive Strategies
Additional Anaesthetic PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
PDL Injection
Technique: needle inserted into the gingival sulcus
at a 30 degree angle towards the tooth bevel placed towards bone advanced until resistance felt anaesthetic injected with continuous
force for about 15 seconds. approx. 0.2 mL of solution 25 vs. 30 gauge needle
PDL Injection
Conventional vs. specific PDL syringes: Malamed (1982):
similar rates of success D’Souza et al (1987):
no sig. difference in anaesthesia achieved. using the pressure syringe resulted in more
spread of anaesthetic to adjacent teeth
PDL Injection: Primary Technique
Melamed 1982: 86% overall Faulkner 1983: 81% overall White 1988: variable, short duration
esp. md. molars Walton 1990: “In reviewing the clinical
and experimental literature…the periodontal ligament injection does not meet all of the necessary requirements for a primary technique.”
PDL Injection: Supplemental Technique
Walton and Abbott 1981: Inadequate pulpal anaesthesia following
IAB 92% overall included situations where multiple PDL
injections required most critical factor was to inject under
strong resistance Smith, Walton, Abbott 1983:
83% overall with high pressure syringe
PDL Injection: Anaesthetic Distribution
Garfunkel et al 1983, Smith and Walton 1983, Tagger et al 1994, Tagger et al 1994* spread along path of least resistance influenced by anatomical structures and
fascial planes through marrow spaces avoided PDL route appears to be a form of intraosseous
injection
PDL Injection: Effects on the Periodontium
Animal histological studies Most studies: no long term evidence
of tissue disruption or inflammation Roahen and Marshall 1990: evidence
of localized external resorption
Adjunctive Strategies
Additional Anaesthetic PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
Intraosseous Injection
Technique for mandibular infiltration Perforate the cortical plate to
introduce LA in medullary bone Bathes the periradicular region in LA 2 commercial systems available:
Stabident (Patterson) X-Tip (Tulsa Dentsply)
Success of Conventional IANB + IO as Measured by
EPT
Dunbar et al.
2% lido 1:100K 90%
Gallatin et al.
3% mepivacaine plain
100%
Guglielmo et al.
2% lido 1:100K 100%
Reitz et al. 2% lido 1:100K 94%
IANB + IO in Cases of Irreversible Pulpitis
Nusstein et al. 1998
Lido 2% 1:100K
91%
Parente et al. 1998
Lido 2% 1:100K
79%/ 91%
Reisman et al. 1997
Mepivacaine 3% plain
80%/ 98%
Nusstein et al. 2003
Lido 2% 1:100K
82% (X-Tip)
Bigby et al. 2006
Articaine 4% 1:100K
86%
Adjunctive Strategies
Additional Block (higher injection) PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
Intrapulpal Anaesthesia
VanGheluwe and Walton 1997: under back-pressure, efficacy of
LA=saline injection Conclusion: back-pressure is the key
to intrapulpal anaesthetic success
Adjunctive Strategies
Additional Anaesthetic PDL Injection Intraosseous Injection Intrapulpal Injection Different anaesthetic
Articaine
Reputation for improved local anaesthetic effect—short linear molecule
Amide local, contains a thiophene ring instead of a benzene ring
Partial hydrolysis by plasma esterases 4% solution—concern with toxicity Potential for methemoglobinemia (like
prilocaine)
Articaine
More effective than other local anaesthetics?
No difference found: Haas et al. 1990 (vs. prilocaine) Vahatalo et al. 1993 (vs. lidocaine) Malamed et al. 2000 (vs. lidocaine) Donaldson et al. 2000 (vs. prilocaine) Claffey et al. 2004 (vs. lidocaine) Mikesell et al. 2005 (vs. lidocaine)
Articaine
Claffey et al. 2004: Articaine vs. lidocaine IANB for
irreversible pulpitis of mandibular teeth Articaine 9/37 (24%) Lidocaine 8/35 (23%) (all subjects had subjective lip
anaesthesia)
Articaine
Paraesthesia? Haas and Lennon 1995: higher incidence
of paraesthesia associated with prilocaine and articaine. Attributed to the higher concentration of drug required for comparable clinical effect
14/11 000 000 injections Statistically higher Clinical relevance? Claffey et al 2004
“clinically rare event”
Articaine
Paraesthesia? Dower 2003 (Dentistry Today) Review article Paraesthesia rates up to 2-4% when
using articaine for lingual blocks or IANBs
RCDSO Dispatch Summer 2005 pg. 26
“Until more research is done, it is the College’s view that prudent practitioners may wish to consider the scientific literature before determining whether to use 4% local anaesthetic solutions for mandibular block injections.”
College Registrar RepliesDispatch Fall 2005 vol. 19,
#4
“This college received legal advice from our general counsel, and from outside counsel, before publishing what we did…The advice we received was that it was certainly within our obligation to advise members to be aware of the literature…”
Articaine
Hillerup and Jensen 2006: Danish population—all cases in Denmark
referred to authors for evaluation 54 injection injuries in 52 patients 54% of all nerve injuries associated with
articaine Substantial increase in number of
injection injuries following introduction of articaine to Danish market in 2000.
Articaine
What about a mandibular infiltration? Recommended by Steve Buchanan Kanaa et al. 2006
Cross-over design comparing articaine and lidocaine for mandibular infiltration for first molars
Anaesthesia measured by maximal EPT X2 Lidocaine 38% effective Articaine 65% effective
Reported Reasons for Mandibular Anaesthesia
Failure
1. Operator Inexperience2. Armamentarium: Deflection of the needle
tip3. Patient factors:
1. Variations in anatomy2. Accessory innervation3. Unpredictable spread of LA4. Local infection5. Pulpal inflammation6. Psychological issues
Kleinknect and Bernstein 1978: positive correlation between anxiety and reported pain during dental treatment
Topical Anaesthetic Benzocaine or
Lidocaine Effectiveness?
Gill and Orr 1979: 15 second application no more effective than placebo
Stern and Giddon 1975: 2-3 minutes=profound soft tissue anaesthesia
Topical Anaesthetic
Recommendations: Dry mucous membranes first 2-3 minutes, but concern with tissue
sloughing Tip of the tongue
Topical Anaesthetic
Benzocaine Spray RCDSO Dispatch 21, 1, Feb/Mar 2007
pp.28-29 Advice to Dentists Benzocaine Sprays and
Methemoglobinemia (MHb) Health Canada—9 suspected cases, none
fatal
Topical Anaesthetic
Benzocaine spray/Methemoglobinemia Recommendations:
Avoid in patients with a history of MHb Consider lidocaine as an alternative Broken/inflamed tissue may promote uptake Use only amount deemed necessary If suspicious, send patient to hospital for
methylene blue tx O2 won’t help, but give it anyways
Methemoglobinemia
Fe2+ ion of the heme group of the hemoglobin molecule is oxidized to Fe3+
Hemoglobin converted to methemoglobin, a non-oxygen binding form of hemoglobin that binds a water molecule instead of oxygen.
Conclusions:
1. Consider topical anaesthetic 2. Re-test using patient’s chief complaint 2. Inject again
Higher More Local Anaesthetic Nerve to Mylohyoid
3. Consider PDL/Intraosseous Anaesthesia 4. Consider Intrapulpal Anaesthesia 5. If they say it hurts, it hurts
Thank you
Questions? Please feel free to contact me:
416-223-1771 [email protected] www.endoasleep.ca