1. NODC - IANB - title · during dental treatment? 6 ... patient loses consciousness General...
Transcript of 1. NODC - IANB - title · during dental treatment? 6 ... patient loses consciousness General...
© 2018 Dr. Stanley F. MalamedAll Rights Reserved
Stanley F. Malamed, DDSDentist Anesthesiologist
Emeritus Professor of Dentistry Herman Ostrow School of Dentistry of U.S.C.
Los Angeles, CA, USA
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I have a relationship with the following companies that may be relevant to this presentation. I am a consultant to:
Stanley F. MALAMED, DDS Emeritus Professor of Dentistry
Herman Ostrow School of Dentistry of USC
Septodont, Inc
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[email protected] [email protected]
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© 2014 Dr. Stanley F. MalamedAll Rights Reserved
2. Does not hurt 1. A painless injection
de St. Georges J. Dentistry Today 23(8): 96-99, August 2004
How Dentists Are Judged By Patients
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How can we PREVENT pain
during dental treatment?
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General Anesthesia
Local Anesthesia
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General Anesthesia
GA requires administration of CNS-depressant drugs until the
patient loses consciousness
General anesthesia represents the controlled
loss of consciousness
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All Rights Reserved
LOCAL ANESTHETICS are the only drugs that actually
PREVENT PAIN
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LOCAL ANESTHETICS are the SAFEST* and MOST EFFECTIVE
drugs in medicine for the PREVENTION & MANAGEMENT
of pain
* when used properly © 2018 Dr. Stanley F. Malamed
All Rights Reserved
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Localanesthetic LA
When a local anesthetic is deposited near a nerve it must diffuse across the nerve membrane INTO the nerve to block nerve conduction
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Local anesthetics
Lidocaine
Articaine
MepivacainePrilocaine
Bupivacaine
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Dentistry’s Most Important Drugs
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Annual LA usage - WORLDWIDE Dentistry
Lidocaine - 1,000,000,000 (estimated) Articaine - 600,000,000
Mepivacaine - 300,000,000 Prilocaine - 50,000,000
Bupivacaine - 10,000,000
Dentistry’s Most Important Drugs
1,960,000,000
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Short-duration (~30 minutes)
• Mepivacaine 3%, Prilocaine 4%
Intermediate-duration (~60 minutes)
• Articaine 4%, Lidocaine 2%, Mepivacaine 2%, Prilocaine 3% or 4% (all with vasoconstrictor)
Long-duration (>90 minutes)
• Bupivacaine 0.5% (with vasoconstrictor)
Local Anesthetics by EXPECTED duration of PULPAL anesthesia
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Deposit a Local Anesthetic Close to a
Nerve and It WILL
Produce Pain Control
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Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic. Stomatologiia. 85(6):6-10, 2006
How often do you encounter inefficiency of local anesthesia, both infiltration and conduction, during manipulation of various tooth groups?
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Tooth group Often Sometimes Rarely Very Rarely Never
Maxillary Incisors 1 3 17 37 3
Maxillary Canines 1 2 23 42 53
Maxillary Premolars 1 8 29 40 43
Maxillary Molars 1 19 31 41 29
Mandibular Incisors 4 6 17 39 55
Mandibular Canines 4 10 23 39 45
Mandibular Premolars 8 29 18 41 25
Mandibular Molars 20 47 32 21 1
Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic.
Stomatologiia. 2006, 85(6):6-10
N = 121
16%
31%
55%
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Tooth group Often Sometimes Rarely Very Rarely Never
Maxillary Incisors 1 3 17 37 3
Maxillary Canines 1 2 23 42 53
Maxillary Premolars 1 8 29 40 43
Maxillary Molars 1 19 31 41 29
Mandibular Incisors 4 6 17 39 55
Mandibular Canines 4 10 23 39 45
Mandibular Premolars 8 29 18 41 25
Mandibular Molars 20 47 32 21 1
N = 121
16%
Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic.
Stomatologiia. 2006, 85(6):6-10
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Why is there a discrepancy in success between the maxillary &
mandibular arches?Maxillary bone = thin = INFILTRATION
Mandibular bone = thick = NERVE BLOCK
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Tooth group Often Sometimes Rarely Very Rarely Never
Mandibular Incisors 4 6 17 39 55
Mandibular Canines 4 10 23 39 45
Mandibular Premolars 8 29 18 41 25
Mandibular Molars 20 47 32 21 1
N = 121
31%
55%
Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic.
Stomatologiia. 2006, 85(6):6-10
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Anesthesia of Mandibular Premolars,
Canine, and Incisors,
can be (usually) easily accomplished
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V3
Foramen Ovale
Inferior alveolar n.
Mandibular n.
Mental n.
Incisive n.
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Incisive nerve block
Mental nerve block
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Needle: 27 gauge shortInsertion: MB fold at or anterior to
mental foramenTarget: Mental nerve as it exits
mental foramenVolume: 0.6 mLAspiration: 5.7%
aka Mental NB (incorrectly)
Incisive NB25
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Insert needle in buccal fold and advance towards mental foramen
AspirateDeposit 0.6 mL outside foramen
aka Mental NB (incorrectly)
Incisive NB26
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VAS = 0 -2
Apply finger pressure for 2 minutes
aka Mental NB (incorrectly)
Incisive NB27
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Visual Analog ScaleVAS
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Tooth group Often Sometimes Rarely Very Rarely Never
Mandibular Incisors 4 6 17 39 55
Mandibular Canines 4 10 23 39 45
Mandibular Premolars 8 29 18 41 25
Mandibular Molars 20 47 32 21 1
N = 121
55%
Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic.
Stomatologiia. 2006, 85(6):6-10
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The traditional ‘Mandibular Block’ has amongst the LOWEST success rates
of all major nerve blocks in the human body
Mandibular anesthesia30
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A dentist will administer approximately 30,000 IANBs in the course of a 20-year career
Pogrel MA, Thamby S. Permanent nerve involvement resulting from
inferior alveolar nerve blocks JADA 2000;131:901-907
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A second problem with mandibular anesthesia, in the adult, is the lack of consistent landmarks.
Lack of consistent anatomy
Mandibular anesthesia
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Once a needle penetrates the skin or mucous membrane,
every injection is BLIND
A basic truism regarding INJECTIONS:33
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Inferior Alveolar NB “Mandibular NB”
Inferior Dental Block
The traditional . . . .
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Inferior Alveolar NB“Mandibular NB”
Inferior Dental Block
The ‘HALSTED Approach’
William Stewart Halsted 1852-1922
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Needle: 25- or 27- gauge longInsertion: soft tissue on medial
border of mandibular ramusTarget: IA nerve on lingual aspect of
ramus prior to entering mandibular foramen
Volume: 1.5 - 1.8 mLAspiration: 10% - 15%
Inferior Alveolar Nerve Block“Mandibular NB”
Inferior Dental Block
VAS = 1 - 5
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Immediately following completion of IANB . . .to obtain
“COMPLETE ANESTHESIA” of the quadrant
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Needle: 25- or 27- gauge longInsertion: mucus membrane distal and
buccal to last mandibular molarTarget: buccal nerve passing over
border of ramusVolume: 0.2 - 0.3 mLAspiration: 0.7%
Buccal NB“Long” Buccal
VAS = 5 - 8
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Following completion of IANB & Buccal NBs . . .
Seat patient comfortably upright
Speeds onset of anesthesia
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FAINTING (syncope)
is the most common medical emergency in dentistry
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FAINTING (syncope)
most often occurs DURING or immediately AFTER the
injection of local anesthetic © 2018 Dr. Stanley F. Malamed
All Rights Reserved
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FAINTING (syncope)
is treated by increasing blood flow to the brain
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The experienced dentist administered the IANB by ‘feel’
Needle is advanced towards lingual aspect of body of mandible until bone is contacted.
Dr. ‘feels’ or ‘senses’ that the needle has contacted bone at the appropriate depth (based on years of clinical experience)
Inferior Alveolar Nerve Block“Mandibular NB”
Inferior Dental Block
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The most common reason for missing the IANB is depositing LA solution too low. (BELOW the mandibular foramen)
The ‘nerve’ is gone! A little higher is a little better
Inferior Alveolar Nerve Block“Mandibular NB”
Inferior Dental Block
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The Importance of AspiratingBefore and
DuringALL injections
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Inferior Alveolar Nerve Block“Mandibular NB”
Inferior Dental Block
VAS = 1 - 5
Needle: 25- or 27- gauge longInsertion: soft tissue on medial border
of mandibular ramusTarget: IA nerve on lingual aspect of
ramus prior to entering mandibular foramen
Volume: 1.5 - 1.8 mL
Aspiration: 10% - 15%Aspiration: 10% - 15%
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Neurovascular bundle
Nerve
Artery
Vein
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What happens if a needle touches an
ARTERY? © 2018 Dr. Stanley F. Malamed
All Rights Reserved
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Facial artery
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The importance of contacting bone in the
inferior alveolar nerve block
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Facial (VII cranial nerve) nerve paralysis
Cause: Introduction of local anesthetic into capsule of parotid gland during inferior alveolar nerve block
Parotid gland
VII
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Depositing LA anywhere along the IA nerve will produce pain control
Inferior Alveolar Nerve Block
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Can we improve the success rate of
mandibular anesthesia ?
So the question is:53
Gow-Gates Mandibular Nerve Block
Vazirani - Akinosi (closed mouth) Mandibular Nerve Block
Periodontal ligament injection (intraligamentary)
Intraosseous anesthesia
Articaine HCl via buccal infiltration
Buffered local anesthetics
Possible Alternatives to the IANB
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TheGOW-GATES
Mandibular Nerve Block
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1973 . . . Gow-Gates Mandibular Nerve Block
1973
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Gow-Gates Mandibular Nerve Block
Depositing LA anywhere along the IA nerve will produce pain control
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George Gow-GatesWestmead Hospital, Sydney - 1993
If a little higher is a little better,a lot higher is a lot better
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The GOW-GATES MANDIBULAR NERVE BLOCK is the only true
mandibular (3rd division, V3) nerve block
Gow-Gates Mandibular Nerve Block59
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AnesthesiaMandibular teeth to midlineBuccal soft tissues to midlineAnterior 2/3 of tongue and floor of oral cavityLingual soft tissues and periosteumBody of mandible, inferior portion of ramusSkin over zygoma, posterior portion of cheek, and temporal region
Gow-Gates Mandibular Nerve Block60
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Needle: 25 gauge longInsertion: At height of ML cusp of
maxillary 2nd molar, just distal to 2nd molar
Target: Lateral aspect of condylar neck
Volume: 2.2 to 3.0 mL***Aspiration: < 2%
*** as per Dr Gow-Gates
Gow-Gates Mandibular Nerve Block61
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A LOW Gow-Gatesis still a
HIGH IANB
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Depositing LA anywhere along the IA nerve will produce pain control
Gow-Gates Mandibular Nerve Block
Inferior Alveolar Nerve Block
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TheVazirani-Akinosi
(closed mouth)Mandibular Nerve Block
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Vazirani-Akinosi Nerve Block
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Gow-Gates Mandibular Nerve Block
Akinosi-Vazirani Nerve Block
Inferior Alveolar Nerve Block
Depositing LA anywhere along the IA nerve will produce pain control
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1982 . . . Periodontal Ligament Injection (PDL) aka Intraligamentary Injection (ILI)
JADA October 1, 1981 103(4): 571-575
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27 gauge short needle
Place interproximally
SLOWLY deposit 0.2 mL per root
Periodontal Ligament Injection (PDL, ILI)69
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27 gauge short needle
Place interproximally
SLOWLY deposit 0.2 mL per root
Periodontal Ligament Injection (PDL, ILI)
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In presence of PERIAPICAL infection:
PDL is not contraindicated, but may not be effective
Periodontal Ligament Injection (PDL, ILI)71
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Contraindication
Periodontal Ligament Injection (PDL, ILI)72
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1980’s . . .
Intraosseous Anesthesia (IO)
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1980’s . . . Intraosseous Anesthesia (IO)
Leonard M, J Amer Dent Assoc October 103(4): 571-575, 1981
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Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2%
lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endodont 24(7):487-491, 1998
88% successful mandibular molars
Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for
teeth with irreversible pulpitis. J Endodont 24(12):826-828, 1998
91% successful mandibular molars
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The guide sleeve remains inplace until you are sure youhave adequate anesthesia.
X-Tip
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ADVANTAGESRelatively comfortable
Single / multiple tooth anesthesiaNo lip / tongue
Intraosseous Anesthesia (IO)
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DISADVANTAGESHighly vascular region
LA ODVasopressor “shakes” or tremor
use 1:200k or plainCan’t locate hole with needle
Intraosseous Anesthesia (IO)
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1980’s . . .
Intraseptal Anesthesia
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Intraseptal (Crestal) Anesthesia
J Dent Res Dent Clin Dent Prospect.Winter 2011 5(1): 17-22, 2011
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J Dent Res Dent Clin Dent Prospect.Winter 2011 5(1): 17-22, 2011
Intraseptal (Crestal) Anesthesia 82
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J Dent Res Dent Clin Dent Prospect.Winter 2011 5(1): 17-22, 2011
Crestal IANB
Onset 7.00 +/- 0.71
3.30 +/- 0.67
<0.001
Duration 23.10 +/- 2.13
32.10 +/- 2.02
<0.05
Pain 1.54 +/- 0.18
3.44 +/- 0.22
<0.001
Volume 0.4 mL +/- 2.07 1.99 mL
Intraseptal (Crestal) Anesthesia 83
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Intraseptal (Crestal) Anesthesia
J Dent Res Dent Clin Dent Prospect.Winter 2011 5(1): 17-22, 2011
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4% with epinephrine
1:100,000 1:200,000
• Synthesized in Germany 1969 • Introduced Germany 1976 • Canada 1985 • USA 2000 • Australia 2005
1st & only Local anesthetic designed for dentistry
Articaine85
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• Duration of pulpal anesthesia (infiltration) = 60 minutes
• Duration of pulpal anesthesia (nerve block) = 60 minutes
• Duration of soft tissue anesthesia = 3 - 5 hours
Articaine 4% Epinephrine
100,000 200,000
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Articaine infiltration as a sole injection
for mandibular anesthesia
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JADA 138(8):1104-1112, 2007
Articaine Lidocaine
Mandibular 2nd Molar 75% 45%
Mandibular 1st Molar 87% 57%
Mandibular 2nd Premolar 92% 67%
Mandibular 1st Premolar 86% 61%
p value for all: >.0001
Pulp test every 3 min
SUCCESS = 80/80 on 2
consecutive tests
Results -1:2007
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Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections.
Int Endod J 35:629-634, 2002
Mandibular Incisors2002
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Infiltration buccal fold by lateral incisor • 94% articaine; 70% lidocaine
Infiltration buccal & lingual by lateral incisor • 97% articaine; 88% lidocaine
Results-1:
Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of
infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
2002
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>70% = 10 min>80% = 10 min>80% = 25 min>90% = 25 min
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Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of
infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
Mandibular Incisors
2002
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Advantages1. Profound pulpal anesthesia2. 30 to 40 minute duration of pulpal anesthesia3. Minimal accessory soft tissue anesthesia
• Tongue
Buccal infiltration - ARTICAINE
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DisadvantageJust like maxillary infiltration,
I can’t think of any, unless it doesn’t work!
Buccal infiltration - ARTICAINE
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Articaine infiltration as a supplement
to IANB
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Kanaa JM, Whitworth JM, Corbett IP, Meechan JGArticaine buccal infiltration enhances the effectiveness of
lidocaine inferior alveolar nerve block.Int Endodont J 42:238-246, 2009 © 2018 Dr. Stanley F. Malamed
All Rights Reserved
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88.9%
66.7%
1st PremolarArticaine infiltration
as a supplement to IANB
88.9%
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91.7%
55.6%
1st MolarArticaine infiltration
as a supplement to IANB
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Buffered Local
Anesthetics
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Can we speed the onset of anesthesia . . .
by buffering the LA solution?
by changing the pH of the LA solution?
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pH ‘Plain’ LA solution = ~6.5 Vasoconstrictor LA solution = ~3.5 Articaine + épi = 5.2 Lemon juice concentrate = 3.3
pH of Local Anesthetics
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0%#
10%#
20%#
30%#
40%#
50%#
60%#
70%#
80%#
90%#
100%#
0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#
Lidocaine#IANB#Mean#
30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsAverage for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean
N = 1078
Most doctorswait ~10 minutes
At 10 minutes:60% pulpal anesthesia
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Why?
Six-Hour Time Course for Pulpal Analgesia (EPT) IANB Second Premolar
95% ofpatients will
(eventually) get numb
if given a 45-minute
waiting period
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IANB: Lidocaine + epinephrine
% clinically effective pulpal anesthesia• 25% at 4 minutes• 40% at 6 minutes
• 60% at 10 minutes• 67% at 15 minutes• 95% at 45 minutes
LidocaineN = 1078
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0%#
10%#
20%#
30%#
40%#
50%#
60%#
70%#
80%#
90%#
100%#
0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#
Ar/caine#IANB#Mean#
Lidocaine#IANB#Mean#
#Buffered#Lido#IANB#
67%
30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine
Buffered Lidocaine
ArticaineN = 222
LidocaineN = 1078
Buffered Lidocaine
N = 18
LIDOCAINE + EPI 1:100ARTICAINE + EPI 1:100
BUFFERED LIDOCAINE + EPI 1:100
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6:37
1:51
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(1) More comfortable injection for patient pH of anesthetic ~7.6
(2) More rapid onset on pulpal anesthesia(3) More profound anesthesia(4) Less post-injection soreness
(5) No effect on duration of action(6) No increase in LA blood level (safety)
When buffering is done properly the following advantages can be expected from the increase in pH:
Buffered Local Anesthetics
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Buffered LA
1. Administer buffered LA IANB 2. DO NOT LEAVE THE PATIENT !!! 3. You know if your block is successful in 2 minutes
Mandibular anesthesia - IANB
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4. Check for pulpal anesthesia: • EPT or Endo-Ice
5. In 2 minutes following IANB either begin tooth preparation or readminister LA
Buffered LAMandibular anesthesia - IANB
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Is the“MANDIBULAR
NERVE BLOCK”Passé ?
So . . .110
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Options:
Incisive (mental) nerve block Gow-Gates mandibular nerve block Akinosi-Vazirani nerve block PDL, Intraosseous, Intraseptal Articaine by mandibular infiltration Buffered local anesthetic
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Incisive (mental) NB (Buffered) lidocaine, articaine, mepivacaine, prilocaine
0.6 - 0.9 mL
RecommendationPremolars and Canine and Incisors
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Infiltration of buffered articaine 0.6 - 0.9 mL buccal fold for ~10 minute treatment
RecommendationCanine or Incisor
Infiltration of buffered articaine 0.6 - 0.9 mL buccal AND lingual for 15 - 30 minute treatment, or . . .
Infiltration of buffered articaine 0.6 mL buccal fold and REPEAT if needed
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IANB or GGMNB utilizing (Buffered) lidocaine, articaine, mepivacaine, followed by (Buffered) articaine buccal infiltration at apex of tooth 0.6 - 0.9 mL
RecommendationPosterior teeth
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Is the“MANDIBULAR
NERVE BLOCK”Passé ?
So . . .
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Is the “Mandibular Block”
Passé?
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THANK YOU for LISTENING!
THANK YOU for LISTENING!
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