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CHAPTER 16Anesthetic Considerationsin Dental SpecialtiesThe techniques of local anesthesia described previously in Once injected, the pH of the anesthetic solution is slowlythis section are valuable to doctors in virtually all areas of increased toward the body’s normal pH of approximatelydental practice. However, speciﬁc needs and problems are 7.4 by tissue ﬂuid buffers. As this conversion occurs, RNH+associated with pain control in particular areas of dentistry. ions lose H+, becoming un-ionized RN ions (according to theThis chapter discusses the dental specialties listed below and Henderson-Hasselbalch equation; see Chapter 1), whichtheir peculiar needs in the area of pain control: now are able to diffuse across the nerve membrane to the• Endodontics interior of the nerve.• Pediatric dentistry Pulpal and periapical inﬂammation or infection can• Periodontics cause signiﬁcant alterations in tissue pH in the affected• Oral and maxillofacial surgery region, including decreased pH (e.g., pus has a pH of 5.5 to• Fixed prosthodontics 5.6) and increased vascularity. Increased acidity has several• Long-duration anesthesia (postsurgical pain control) negative aspects.1 It severely limits the formation of RN,• Dental hygiene increasing the formation of RNH+. RNs that do diffuse into the nerve ﬁnd a normal tissue pH of 7.4 within the nerve and re-equilibrate into both RN and RNH+ forms. TheseENDODONTICS RNH+ forms are then able to enter into and block sodium channels, blocking nerve conduction. But with fewer totalEffects of Inﬂammation on Local Anesthesia anesthetic molecules (RN’s and RNH+’s) diffusing into theInﬂammation and infection lower tissue pH, altering the nerve, there is a greater likelihood that incomplete anesthesiaability of a local anesthetic to provide clinically adequate will develop. The overall effect of ion entrapment is to delaypain control. As a review, local anesthetics are weak bases the onset of anesthesia and possibly interfere with nerve(pKa, 7.5 to 9.5) and are not water-soluble compounds. blockade.2 Ion entrapment changes the products of inﬂam-Combined with hydrochloric acid (HCl), local anesthetics mation, so they inhibit anesthesia by directly affecting theare injected in their acid–salt form (e.g., lidocaine HCl), nerve. Brown demonstrated that inﬂammatory exudatesimproving their water solubility and stability. The pH of enhance nerve conduction by lowering the response thresh-a “plain” local anesthetic is approximately 6.5, and the pH old of the nerve,1 which may inhibit local anesthesia. Thisof one containing a vasoconstrictor is approximately 3.5. causes blood vessels in the region of inﬂammation to becomeIn an acidic solution, hydrogen ions (H+) are “ﬂoating unusually dilated, allowing more rapid removal of the anes-around.” If we abbreviate the anesthetic drug as RN (the thetic from the site of injection. This leads to an increasedun-ionized form of the local anesthetic), then some of these possibility that resultant local anesthetic blood levels will beRNs will attach to an H+, forming the cationic form of the elevated (from those seen in normal tissue).2local anesthetic (RNH+). The more acidic the anesthetic Although there are no magic bullets for attaining pro-solution, the greater the number of H+ ions available, and found pain control in teeth requiring pulpal extirpation,the greater the percentage of RNH+ found in the solution. several methods may increase the likelihood of success. First,Because only the RN ionic form is lipid soluble and is administer the local anesthetic at a site distant from theable to cross the lipid-rich nerve membrane, the lower the area of inﬂammation. It is undesirable to inject anestheticpH of the anesthetic solution and the tissue into which it solutions into infected tissue because this may cause theis injected, the lower is the percentage of RN ions, the infection to spread to uninvolved regions.3,4 Administrationslower is the onset, and the less profound is the resultant of local anesthetic solution into a site distant from theanesthesia. involved tooth is more likely to provide adequate pain 277
278 PART III Techniques of Regional Anesthesia in Dentistrycontrol because of the existence of normal tissue conditions.Therefore, regional nerve block anesthesia is a major factorin pain control for the pulpally involved tooth. Second,use a buffered local anesthetic solution. Administrationof a solution of local anesthetic with a pH in the range of7.35 to 7.5 increases the percentage of RN ionic formapproximately 6000-fold (lidocaine HCl with epinephrine[pH 3.5] = 0.004% of ionic forms RN; pH 7.4 = 24.03% RN).In studies with “normal” teeth, 71% of patients receivinga buffered local anesthetic achieved successful pulpal anes-thesia within 2 minutes versus 5 minutes 17 seconds for Figure 16-1. Stabident intraosseous injection technique.unbuffered local anesthetic.5 Although at the time of thiswriting (January 2012), no clinical trials of buffered localanesthetics have been published, anecdotal reports fromendodontists indicate that they have seen a considerablygreater incidence of successful anesthesia on teeth requiringpulpal extirpation.6Methods of Achieving AnesthesiaThe following techniques are recommended for providingpain control in pulpally involved teeth: local inﬁltration,regional nerve block, intraosseous injection, intraseptalinjection, periodontal ligament injection, and intrapulpalinjection. The order in which these techniques are discussedis the typical sequence in which they are normally used to Figure 16-2. X-Tip intraosseous injection technique.achieve pain control when one seeks to extirpate pulpaltissues. 2. While holding the perforator perpendicular to theLocal Inﬁltration (Supraperiosteal Injection). Local inﬁl- cortical plate, gently push it through the attachedtration is commonly used to provide pulpal anesthesia in gingiva until its tip rests against bone.maxillary teeth. It is usually effective in endodontic proce- 3. Activate the handpiece and apply pressure on thedures when severe inﬂammation or infection is not present. perforator in a “pecking” motion until a sudden loss ofLocal inﬁltration should not be attempted in a region where resistance is felt.infection is obviously (clinically or radiographically) present 4. Withdraw the perforator and dispose of it safely.because of the possible spread of infection to other regions 5. Insert the local anesthetic needle into the hole andand a greatly decreased rate of success. When infection is deposit the volume of local anesthetic appropriate forpresent, other techniques of pain control should be relied on. the procedure (see charts in Chapter 15).Inﬁltration anesthesia is often effective at subsequent end- Cardiovascular absorption of the local anesthetic after IOodontic visits, if adequate débridement and shaping of the injection is more rapid than after the other techniquescanals have been previously accomplished. described.16,17 Transient elevations in heart rate were noted in 67% (28/42) of healthy patients receiving 2% lidocaineRegional Nerve Block. Regional nerve block anesthesia is with 1 : 100,000 epinephrine via IO injection. The heart raterecommended in cases where inﬁltration anesthesia may be returned to within 5 beats of normal within 4 minutes inineffective or contraindicated. These techniques are dis- 79% of patients. No signiﬁcant increase was noted when 3%cussed in detail in Chapters 13 and 14. Regional nerve block mepivacaine was injected IO in the same patients.17is likely to be effective because the anesthetic solution is The use of epinephrine-containing local anesthetics indeposited at a distance from the inﬂammation, where tissue the IO technique is not contraindicated in healthy, non–pH and other factors are more normal. cardiovascular risk patients. However, where signiﬁcant car- diovascular risk or other relative contraindications toIntraosseous Injection. The intraosseous (IO) injection has administration of epinephrine exist, a “plain” local anes-experienced a resurgence of enthusiasm in recent years.7-15 thetic is a good alternative for IO anesthesia, keeping in mindIO injections can provide anesthesia profound enough to that neither the depth nor duration of anesthesia will be asallow painless access into the pulp chamber for removal of good as expected in a non-pulpally involved tooth.pulpal tissue. IO technique is described in Chapter 15 and isreviewed here (Figs. 16-1 and 16-2): Intraseptal Injection. This is a variation of IO and peri-1. Apply topical anesthetic at the site of the injection to odontal ligament (PDL) injections and may be used as anesthetize the soft tissue. an alternative to these techniques. It is more successful in
CHAPTER 16 Anesthetic Considerations in Dental Specialties 279 may accompany the injection. Clinical pain relief follows almost immediately, permitting instrumentation to proceed atraumatically. Occasionally, the anesthetic needle does not ﬁt snugly into the canal, preventing the increased pressure normally encountered in the intrapulpal injection. In this situation, the anesthetic can be deposited in the chamber or canal. Anesthesia is produced only by the pharmacologic action of the drug; there is no pressure anesthesia. Instrumenta- tion may begin approximately 30 seconds after the drug is deposited. With the growing popularity of IO anesthesia, the need for intrapulpal injection to provide profound pain control in cases of irreversible pulpitis has decreased.Figure 16-3. For the intraseptal injection, a 27-gauge short Today there are but few occasions when all of the tech-needle is inserted into the intraseptal bone distal to the tooth to be niques discussed fail to provide clinically acceptable painanesthetized. control, and intrapulpal anesthesia cannot be attempted until the pulp is exposed. The following sequence of treat- ment may be of value on these rare occasions:younger patients because of decreased bone density. Intra- 1. Use slow-speed high-torque instrumentation (whichseptal anesthesia is described in Chapter 15 and proceeds as usually is less traumatic than the high-speed low-torquefollows18: option).1. Anesthetize the soft tissues at the injection site via local 2. Use (minimal or moderate) sedation (which helps to inﬁltration. decrease the patient’s response to painful stimuli).2. Insert a 27-gauge short needle into the intraseptal bone Nitrous oxide–oxygen inhalation sedation is a readily distal to the tooth to be anesthetized (Fig. 16-3). available, safe, and highly effective method of relaxing a3. Advance the needle ﬁrmly into the cortical plate of patient and elevating his or her pain reaction threshold. bone. 3. If, after steps 1 and 2, the pulp chamber is opened,4. Inject about 0.2 mL of anesthetic. administer direct intrapulpal anesthesia. This is usually Considerable resistance must be encountered as the anes- effective despite the brief period of pain associated withthetic is being deposited. If administration of the anesthetic intrapulpal administration.is easy, the needle tip is most likely in soft tissue, not in bone. 4. If a high level of pain persists and it still is not possible to enter the pulp chamber, then the following sequencePeriodontal Ligament Injection. The PDL injection may be should be considered:an effective method of providing anesthesia in pulpally a. Place a cotton pellet saturated with local anestheticinvolved teeth if infection and severe inﬂammation are not loosely on the pulpal ﬂoor of the tooth.present. This technique is discussed in Chapter 15. By way b. Wait 30 seconds; then press the pellet more ﬁrmlyof review, a 27-gauge short needle is ﬁrmly placed between into the dentinal tubules or the area of pulpalthe interproximal bone and the tooth to be anesthetized. The exposure. This area may be sensitive initially butbevel of the needle should face the tooth (although bevel should become insensitive within 2 to 3 minutes.orientation is not critical for success). It is appropriate to c. Remove the pellet and continue use of the slow-bend the needle if necessary to gain access. A small volume speed drill until pulpal access is gained; then perform(0.2 mL) of local anesthetic is deposited under pressure for direct injection into the pulp.each root of the tooth. It may be necessary to repeat the PDL With most endodontic procedures, difﬁculty in providinginjection on all four sides of the tooth. Computer-controlled adequate anesthesia occurs only at the ﬁrst appointment.local anesthetic delivery (C-CLAD) devices enable the PDL Once the pulp tissue has been extirpated, the need for pulpalinjection to be administered more successfully and more anesthesia disappears. Soft tissue anesthesia may be neces-comfortably than an injection given with a traditional dental sary at ensuing appointments for comfortable placement oflocal anesthetic syringe. the rubber dam clamp, but if adequate tooth structure remains, this may not be necessary. Some patients respondIntrapulpal Injection. The intrapulpal injection provides unfavorably to instrumentation of their root canals, evenpain control both by the pharmacologic action of the local when the canals have been thoroughly débrided. If thisanesthetic and by applied pressure. This technique may be occurs, inﬁltration (in the maxillary or mandibular incisorused once the pulp chamber is exposed surgically or patho- region [with articaine HCl]), intrapulpal anesthesia, orlogically. The technique is described in Chapter 15. topical anesthetic may be used. Apply a small amount of When intrapulpal injections are administered properly, topical anesthetic ointment onto the ﬁle or reamer beforea brief period of sensitivity, ranging from mild to severe, inserting it into the canal. This helps to desensitize the
280 PART III Techniques of Regional Anesthesia in Dentistryperiapical tissues during instrumentation of the canals.Patients may react to ﬁlling of the canals. Local anesthesia TABLE 16-1should be considered before this stage of treatment is started. Maximum Recommended Doses (MRDs) of Local Anesthetics Manufacturer’s mg/kgPEDIATRIC DENTISTRY Drug Formulation MRD (mg/lb)Pain control is one of the most important aspects of behav- Articaine 4% with N/A 7.0 (3.2)ioral management in children undergoing dental treatment. epinephrineUnpleasant childhood experiences have made many adults Lidocaine Plain 300 4.4 (2.0)acutely phobic with regard to dental treatment. Today, Lidocaine Epinephrine 500 7.0 (3.2)however, many local anesthetic drugs are available to make 1 : 100,000pain management relatively easy. Special concerns in pediat- Lidocaine Epinephrine 500 7.0 (3.2) 1 : 50,000ric dentistry relevant to local anesthetic include anesthetic Mepivacaine Plain 400 6.6 (3.0)overdose (toxic reaction), self-inﬂicted soft tissue injury Mepivacaine With 400 6.6 (3.0)related to the prolonged duration of soft tissue anesthesia, levonordefrinand technique variations related to the smaller skulls and Prilocaine Plain 600 8.0 (3.6)differing anatomy of younger patients. Prilocaine With epinephrine 600 8.0 (3.6) Bupivacaine With epinephrine 90 —Local Anesthetic OverdoseOverdose from a drug occurs when its blood level in a targetorgan (e.g., brain and myocardium for local anesthetics)becomes excessive (see Chapter 18). Undesirable (toxic) multiple-quadrant dentistry and the concomitant use ofeffects may be caused by intravascular injection or adminis- sedative drugs (especially opioids).19 When treating a smallertration of large volumes of the drug. Local anesthetic toxicity child, the dentist should maintain strict adherence to MRDsdevelops when the blood level of the drug in the brain or (Table 16-1) and should anesthetize only that quadrant thatmyocardium becomes too high. Therefore local anesthetic is currently being treated.toxicity relates to the volume of drug reaching the cerebro- Cheatham and associates surveyed 117 dentists who regu-vascular and cardiovascular systems and to the blood volume larly treated children about their local anesthetic usage.26of the patient. Once the blood level of a drug reaches toxic They found that the lighter the weight of the patient, thelevels, the drug exerts unwanted and possibly deleterious more likely the doctor was to administer an overly largesystemic actions that are consistent with its pharmacological dose of the local anesthetic, based on milligrams per kilo-properties. Local anesthetic toxicity produces central nervous gram of body weight. For example, a 13-kg patient shouldsystem (CNS) and cardiovascular system (CVS) depression, receive no more than 91 mg of lidocaine (based on an MRDwith reactions ranging from mild tremor to tonic–clonic of 7.0 mg/kg). The range of doses administered by dentistsconvulsions (CNS), or from a slight decrease in blood pres- treating children was 0.9 to 19.3 mg/kg. As the patient’ssure and cardiac output to cardiac arrest (CVS). weight increased, the number of milligrams per pound or Disproportionately high numbers of deaths and serious kilogram reached lower and safer levels, the maximummorbidities caused by local anesthetic overdose have mg/kg range falling to 12.6 mg/kg in the 20-kg patient andoccurred in children, leading to the assumption that local to 7.2 mg/kg in the 35-kg patient. The mean dose of localanesthetics are more toxic in children than in adults.19,20 This anesthetic also fell when the patient’s weight increased, fromis untrue; it is the safety margin of local anesthetics in small 5.4 mg/kg in the 13-kg patient to 4.8 mg/kg in the 20-kgchildren that is low. Given an equal dose (mg) of local anes- patient to 3.8 mg/kg in the 35-kg patient (Table 16-2).thetic, a healthy adult patient with a larger body weight and Administration of large volumes of local anesthetic is notgreater blood volume will have a lower blood level of anes- necessary when one is seeking to achieve pain control inthetic than the child patient of lesser weight and smaller younger patients. Because of differences in anatomy (see theblood volume. Blood volume, to a large degree, relates to following discussion of “Techniques of Local Anesthesia inbody weight: the greater the body weight, the greater the Pediatric Dentistry”), smaller volumes of local anestheticsblood volume (except in cases of marked obesity). provide the depth and duration of pain control usually nec- Maximum recommended doses (MRDs) of all drugs essary to successfully complete planned dental treatment inadministered by injection should be calculated by body younger patients.weight and should not be exceeded, unless it is absolutely Because all injectable local anesthetics possess vasodilat-essential to do so.20 For example, two cartridges of 3% mepi- ing properties, leading to more rapid vascular uptake andvacaine (54 mg per cartridge) exceed the MRD for a 15-kg a shorter duration of adequate anesthesia, it is strongly rec-(33-lb) child of 66 mg. Unfortunately, lack of awareness of ommended that a vasopressor be included in the local anes-maximum doses has led to fatalities in children.21–25 The thetic solution unless there is a compelling reason for it toease with which a lighter-weight child may be overdosed be excluded.27 Many treatment appointments in pediatricwith local anesthetics is compounded by the practice of dentistry do not exceed 30 minutes in duration; therefore
CHAPTER 16 Anesthetic Considerations in Dental Specialties 281TABLE 16-2Local Anesthetic Administration by Dentists Who Treat Children (n = 117) PatientAge Weight, kg Mean Dose, mg/kg Mean, mg/kg Range, mg Range, mg/kg Recommended (MRD), mg/kg 2 13 69.9 5.4 12-252 0.9-19.3 Lidocaine 4.4-7.0 Mepivacaine 4.4-6.0 5 20 96.5 4.8 18-252 0.9-12.610 35 135 3.8 36-252 1.0-7.2Modiﬁed from Cheatham BD, Primosch RE, Courts FJ: A survey of local anesthetic usage in pediatric patients by Florida dentists, J Dent Child 59:401–407,1992.TABLE 16-3 BOX 16-1 Factors Adding to Increased Risk of LocalLocal Anesthetic Choice by Dentists Who Treat Children Anesthetic Overdose in Younger Patients(n = 117) 1. Treatment plan: all four quadrants treated usingAnesthetic Formulation Percent Employing local anesthetic in one visit.2% lidocaine + 1 : 100,000 epinephrine 69 2. Local anesthetic administered is a plain (no3% mepivacaine 11 vasopressor) solution.2% lidocaine 8 3. Full cartridges (1.8 mL) administered with each2% mepivacaine + 1 : 20,000 8 injection. levonordefrin 4. Local anesthetic administered to all four quadrantsOther anesthetics 4 at one time.Adapted from Cheatham BD, Primosch RE, Courts FJ: A survey of local 5. Exceeding the maximum dosage based on patient’sanesthetic usage in pediatric patients by Florida dentists, J Dent Child body weight.59:401–407, 1992. Adapted from Cheatham BD, Primosch RE, Courts FJ: A survey of local anesthetic usage in pediatric patients by Florida dentists, J Dent Child 59:401–407, 1992.use of a local anesthetic containing a vasopressor is con-sidered to be unnecessary and unwarranted. It is thoughtthat increased duration of soft tissue anesthesia, especiallyafter inferior alveolar nerve block, increases the risk of self- administration. Fortunately, most patients do not encounterinﬂicted soft tissue injury. A non–vasopressor-containing problems related to prolonged soft tissue anesthesia, butlocal anesthetic is frequently used (most often, mepivacaine most of those who do are younger, oldest old (>85 years), or3%). Providing 20 to 40 minutes of pulpal anesthesia, mepi- mentally or physically disabled. Problems related to softvacaine 3% is considered the appropriate drug for this tissue anesthesia most often involve the lower lip. Much lessgroup of patients; this is true, provided that treatment is frequently, the tongue is injured, and rarely, the upper lip islimited to one quadrant per visit. However, when multiple involved.quadrants are to be treated (and anesthetized) on a smaller, College and associates reported an 18% incidence of self-lighter-weight patient in a single visit, administration of inﬂicted soft tissue injury in patients younger than 4 yearsa “plain” drug into multiple injection sites increases the of age receiving inferior alveolar nerve block.29 From 4 to 7potential risk of overdose. Use of a local anesthetic contain- years, the rate was 16%, from 8 to 11 years, 13%, and froming a vasopressor is strongly recommended whenever mul- 12 years on, 7%.tiple quadrants are anesthetized in the smaller pediatric Several preventive measures can be implemented:patient. Sixty-nine percent of doctors treating children 1. Select a local anesthetic with a duration of action that isadministered lidocaine with epinephrine as their primary appropriate for the length of the planned procedure.anesthetic (Table 16-3).26 Some local anesthetics provide pulpal anesthesia of Factors increasing the risk of local anesthetic overdosage adequate duration (20 to 40 minutes) for restorativein younger patients are presented in Box 16-1.28 procedures in children, with a relatively short duration of soft tissue anesthesia (1 to 3 hours, instead of 4 or 5)Complications of Local Anesthesia (Table 16-4). It should be kept in mind, however, thatSelf-inﬂicted soft tissue injury—accidental biting or chewing investigators have not demonstrated a relationshipof the lip, tongue, or cheek—is a complication associated between the use of plain local anesthetics and awith residual soft tissue anesthesia (Fig. 16-4). Soft tissue reduction in soft tissue trauma. The clinician mustanesthesia lasts considerably longer than pulpal anesthesia consider the advisability of using a local anestheticand may persist for 4 or more hours after local anesthetic containing a vasopressor when treating multiple
282 PART III Techniques of Regional Anesthesia in Dentistry A B Figure 16-4. Lip trauma caused by biting while the area was anesthetized.TABLE 16-4Relative Durations of Pulpal and Soft Tissue Anesthesia Approximate Approximate 10 11 8 Pulpal Anesthesia, Soft TissueDrug min Anesthesia, hr 6 7 9Mepivacaine plain 20-40 3-4Prilocaine plain (inﬁltration) 10 1 1 2 -2 1 2 3 4 5Lidocaine plain 5-10 1-1 1 2 12 11 6 7 9 10 quadrants in view of the decreased margin of safety of local anesthetics in smaller children. 82. Administer phentolamine mesylate (Oraverse) at the conclusion of the traumatic portion of the dental procedure. Discussed more completely in Chapter 20, Figure 16-5. Upper and lower jaws in a 4-year-old child with erupted primary teeth and unerupted permanent teeth. 1, First phentolamine mesylate is an alpha-adrenergic (central) incisor of primary dentition; 2, second (lateral) incisor of antagonist that, when injected into the site where local primary dentition; 3, canine of primary dentition; 4, ﬁrst molar of anesthetic with vasopressor was previously deposited, primary dentition; 5, second molar of primary dentition; 6, ﬁrst produces vasodilation, increasing blood ﬂow through (central) incisor of permanent dentition; 7, second (lateral) incisor the area, thereby increasing the speed with which the of permanent dentition; 8, canine of permanent dentition; 9, ﬁrst local anesthetic drug diffuses out of the nerve. The premolar of permanent dentition; 10, second premolar of perma- duration of residual soft tissue anesthesia is signiﬁcantly nent dentition; 11, ﬁrst molar of permanent dentition; 12, second reduced. Phentolamine mesylate has been approved by molar of permanent dentition. (From Abrahams PH, Marks SC Jr, the Food and Drug Administration (FDA) for use in Hutchings RT: McMinn’s color atlas of human anatomy, ed 5, patients 6 years of age and older and weighing more St Louis, 2003, Mosby.) than 15 kg (33 lb).30,313. Advise both the patient and the accompanying adult about the possibility of injury if the patient bites, sucks, to diminish, and coating the involved area with a lubricant or chews on the lips, tongue, or cheeks, or ingests hot (petroleum jelly) to help prevent drying, cracking, and pain. substances while anesthesia persists.4. Some doctors reinforce the verbal warning to the Techniques of Local Anesthesia in patient and the adult by placing a cotton roll in the Pediatric Dentistry mucobuccal fold (held in position by dental ﬂoss Local anesthetic techniques in children do not differ greatly through the teeth) if soft tissue anesthesia is still present from those used in adults. However, the skulls of children do at the time of the patient’s discharge. Warning stickers have some anatomic differences from those of adults. For are available to help prevent soft tissue trauma. instance, maxillary and mandibular bone in children gener- Management of self-inﬂicted soft tissue trauma consists ally is less dense, which works to the dentist’s advantageof reassuring the patient, allowing time for anesthetic effects (Fig. 16-5). Decreased bone density allows more rapid and
CHAPTER 16 Anesthetic Considerations in Dental Specialties 283complete diffusion of the anesthetic solution. Also, children bone in the mandible in younger children. The rate of successare smaller; thus standard injection techniques usually can of mandibular inﬁltration anesthesia decreases somewhatbe completed with decreased depth of needle penetration. for primary mandibular molars as the child increases in age. The technique of supraperiosteal inﬁltration in the mandibleMaxillary Anesthesia. All primary teeth and permanent is the same as in the maxilla. The tip of the needle is directedmolars can be anesthetized by supraperiosteal inﬁltration toward the apex of the tooth, in the mucobuccal fold, andin the mucobuccal fold. The posterior superior alveolar approximately one fourth to one third (0.45 to 0.6 mL) car-(PSA) nerve block is rarely necessary because of the effec- tridge is slowly deposited.tiveness of inﬁltration in children. However, in some indi- The IANB has a greater success rate in children than inviduals, the morphology of the bone surrounding the apex adults because of the location of the mandibular foramen.of the permanent ﬁrst molar does not permit effective inﬁl- The mandibular foramen in children lies distal and moretration of local anesthetic, because the zygomatic process inferior to the occlusal plane. Benham37 demonstrated thatlies closer to the alveolar bone in children. A PSA nerve the mandibular foramen lies at the height of the occlusalblock may be warranted in this clinical situation. A 27-gauge plane in children and extends an average of 7.4 mm aboveshort dental needle should be used and the depth of needle the occlusal plane in adults. He also found that there is nopenetration modiﬁed to meet the smaller dimensions of age-related difference as to the anteroposterior position ofthe pediatric patient, to minimize the risk of overinsertion the foramen on the ramus.leading to hematoma. As an alternative to the PSA, Rood32 The technique for an IANB is essentially identical forhas suggested using buccal inﬁltrations on both the mesial adults and children. The syringe barrel is placed in the cornerand the distal of the maxillary ﬁrst molar to avoid a pro- of the mouth on the opposite side. The average depth ofminent zygomatic process. The anterior superior alveolar penetration to bone is approximately 15 mm, although this(ASA) nerve block also can be used in children, as long as may vary signiﬁcantly with the size of the mandible and theit is realized that the depth of penetration is probably just age of the patient. As with the adult, bone should be con-slightly greater than with a supraperiosteal injection (because tacted before any solution is deposited. In general, the moreof the lower height of the maxillae in children). Generally, inferior location of the mandibular foramen in children pro-there are few indications for the PSA or ASA nerve block vides a greater opportunity for successful anesthesia. “Tooin children. low” injections are more likely to be successful. In clinical Occasionally, a maxillary tooth remains sensitive after a situations, the success rate for well-behaved children usuallysupraperiosteal injection because of accessory innervation exceeds 90% to 95%.from the palatal nerves33 or widely ﬂared palatal roots. Palatal Because of the decreased thickness of soft tissue overlyinganesthesia can be attained in children through the nasopala- the inferior alveolar nerve (about 15 mm), a 25- or 27-gaugetine and greater (anterior) palatine nerve blocks. The tech- short needle may be recommended for the IANB in younger,nique for a nasopalatine nerve block proceeds exactly as smaller patients. This should be changed to a long needledescribed in Chapter 13. That for a greater palatine nerve once the patient is of sufﬁcient size that a short needle doesblock is as follows: The administrator visualizes a line from not reach the injection site without entering tissue almost tothe gingival border of the most posterior molar that has its hub.erupted to the midline. The needle is inserted from the The buccal nerve may be anesthetized if anesthesia of theopposite side of the mouth, distal to the last molar, bisecting buccal tissues in the permanent molar region is necessary.this line. If the child has only primary dentition, the needle The needle tip is placed distal and buccal to the most poste-is inserted approximately 10 mm posterior to the distal rior tooth in the arch. Approximately 0.3 mL of solution issurface of the second primary molar, bisecting the line drawn deposited.toward the midline. The Vazirani-Akinosi and Gow-Gates mandibular nerve An intrapapillary injection also can be used to achieve blocks also can be used in children. Akinosi38 advocates thepalatal anesthesia in young children. Once buccal anesthesia use of short needles with this technique in children. He statesis effective, the needle (27-gauge short) is inserted horizon- that the technique appears less reliable in children, which hetally into the buccal papilla just above the interdental septum. relates to the difﬁculty of judging the depth of penetrationLocal anesthetic is injected as the needle is advanced toward necessary in a growing child. The Gow-Gates mandibularthe palatal side. This should cause ischemia of the soft block can be used successfully in children.39 However, thesetissue.34 injections are rarely necessary in pediatric dentistry because of the effectiveness of mandibular inﬁltration (when theMandibular Anesthesia. Supraperiosteal inﬁltration usually dentition is composed entirely of primary teeth) and theis effective in providing pain control in mandibular primary relative ease with which one can achieve inferior alveolarteeth.35,36 Sharaf reported that buccal inﬁltration in the man- and incisive nerve block anesthesia.dible in 80 children (ages 3 to 9 years) was as effective as The incisive nerve block provides pulpal anesthesia to theinferior alveolar nerve block (IANB) anesthesia in all situa- ﬁve primary mandibular teeth in a quadrant. Deposition oftions, except when pulpotomy was performed on the primary anesthetic solution outside the mental foramen with appli-second molar.35 This was the result of decreased density of cation of ﬁnger pressure for 2 minutes provides a very high
284 PART III Techniques of Regional Anesthesia in Dentistrydegree of success. The mental foramen usually is located recommended for use in hemostasis.42,43 Epinephrine is mostbetween the two primary mandibular molars. A volume of commonly used for hemostasis in a concentration of0.45 mL ( 1 4 of a cartridge) is suggested. 1 : 50,000 (0.2 mg/mL). Generally, small volumes (not exceed- The PDL injection has been well accepted in pediatric ing 0.1 mL) are deposited when used for hemostasis. Epi-dentistry and can be used as an alternative to supraperiosteal nephrine also provides excellent hemostasis in a concentrationinjection. It provides the doctor with the means to achieve of 1 : 100,000, although surgical bleeding is inversely propor-anesthesia of proper depth and duration on one tooth, tional to the concentration of vasopressor administered.without unwanted residual soft tissue anesthesia. The PDL When plain local anesthetic is inﬁltrated (e.g., 3% mepiva-is also useful when a child has discrete carious lesions in caine) during periodontal surgery, blood loss is two to threemultiple quadrants. See Chapter 15 for a complete discus- times that noted when 2% lidocaine with 1 : 100,000 epi-sion of technique for the PDL injection. It is recommended nephrine is administered.44 Buckley and associates demon-that the described technique be scrupulously adhered to, to strated that use of a 1 : 50,000 epinephrine concentrationavoid physiologic (pain) and psychological (fear) trauma to produced a 50% decrease in bleeding during periodontalthe patient. The PDL injection is not recommended for use surgery from that seen with a 1 : 100,000 concentration (withon primary teeth because of the possibility of enamel hypo- 2% lidocaine).45 However, epinephrine is not a drug withoutplasia occurring in the developing permanent tooth.40 systemic effects and some undesirable local effects. Studies have shown that even the small volumes of epinephrine used in dentistry can signiﬁcantly increase the concentrations ofPERIODONTICS plasma catecholamine and can alter cardiac function.46Special requirements for local anesthesia in periodontal pro- Therefore, it is prudent to administer the smallest volume ofcedures center on the use of vasopressors to provide hemo- the least concentrated form of epinephrine that providesstasis and the use of long-duration local anesthetics for clinically effective hemostasis.postoperative pain control. Postsurgical pain management, As tissue levels of epinephrine decrease after its injectionincluding the use of long-duration anesthesia, is discussed for hemostasis, a rebound vasodilation develops. Sveen dem-as a separate subject later in this chapter. onstrated that postsurgical bleeding (at 6 hours) occurred in Soft tissue manipulation and surgical procedures are 13 of 16 (81.25%) patients receiving 2% lidocaine with epi-associated with hemorrhage, especially when the tissues nephrine for surgical removal of a third molar, whereas 0 ofinvolved are not healthy. Administration of local anesthetics 16 patients who underwent surgery with 3% mepivacainewithout vasopressors proves to be counterproductive because bled at 6 hours post surgery.44 Bleeding interfered with post-the vasodilating property of the local anesthetic increases operative healing in 9 of 16 (56.25%) patients receiving lido-bleeding in the region of the injection.41 Vasopressors are caine with epinephrine, compared with 25% of patientsadded to counteract this undesirable property of local receiving no epinephrine. Evidence also suggests that the useanesthetics. of epinephrine in local anesthetics during surgery may The pharmacology of vasopressors is more completely produce an increase in postoperative pain.47discussed in Chapter 3. As a review, vasopressors produce Many doctors use a 30-gauge short needle to depositarterial smooth muscle contraction through direct stimula- anesthetics for hemostasis. Their rationale is that the thinnertion of α receptors located in the wall of the blood vessel. needle produces a smaller defect (puncture) in the tissue.Consequently, it follows that local anesthetics with vasopres- If a small puncture is important, then the 30-gauge needlesors used for hemostasis must be injected directly into the should be used, but only for this purpose (hemostasis).region where the bleeding is to occur. The 30-gauge short needle should not be used if there is Pain control for periodontal procedures should be the possibility of positive aspiration of blood, or if anyachieved through nerve block techniques, including poste- depth of soft tissue must be penetrated. Aspiration of bloodrior superior alveolar, inferior alveolar, and infraorbital through a 30-gauge needle is difﬁcult (although possible).nerve blocks. Saadoun18 has shown that the intraseptal tech- A 27-gauge needle can be used for local inﬁltration tonique is very effective for periodontal ﬂap surgical proce- achieve hemostasis when vascularity is a problem, or in anydures. It decreases the total volume of administered anesthetic other area of the oral cavity without an increase in patientand the volume of blood lost during the procedure. Local discomfort.anesthetic solutions used for nerve blocks should include avasopressor in a concentration not greater than 1 : 100,000epinephrine or 1 : 20,000 levonordefrin. An epinephrine con- ORAL AND MAXILLOFACIAL SURGERYcentration of 1 : 50,000 is not recommended for pain control Pain control during surgical procedures is achieved throughbecause depth, duration, and success rates are no greater administration of local anesthetics, given alone or in combi-than those seen with anesthetics containing 1 : 100,000 or nation with inhalation sedation, intravenous sedation, or1 : 200,000 epinephrine. general anesthesia. As is the case with periodontal surgery, Epinephrine is the drug of choice for local hemostasis. long-duration local anesthetics play an important role inNorepinephrine (which is not available in North America postoperative pain control and are discussed separately.in dental local anesthetics) can produce marked tissue isch- Local anesthetic techniques used in oral surgery do notemia, which can lead to necrosis and sloughing and is not differ from those employed in nonsurgical procedures.
CHAPTER 16 Anesthetic Considerations in Dental Specialties 285Therefore it should be expected that instances of partial or Chapter 14 provide only partial anesthesia in this situation.incomplete anesthesia will occur. Oral and maxillofacial sur- The PDL injection usually corrects the lack of pain controlgeons frequently treat patients who have received intrave- in this circumstance.nous sedation or general anesthesia before the start ofsurgery. These techniques act to modify the patient’s reaction FIXED PROSTHODONTICSto pain, leading to a decrease in the number of reportedinstances of inadequate local anesthesia. When preparing a tooth for full coverage (crown or bridge), Local anesthesia is administered almost routinely to it is necessary to place a provisional restoration over thepatients for third molar extractions under general anesthe- prepared tooth. Although achieving pain control might notsia. The reasons for this are as follows: be difﬁcult at the initial visit, it may be difﬁcult at subsequent1. General anesthesia does not prevent pain. General visits to adequately anesthetize the prepared tooth. The anesthesia prevents the patient from responding reason for this is probably the provisional restoration. Overly outwardly to painful stimulation. Blood pressure (BP), high restorations produce traumatic occlusion, which can heart rate (HR), and respiratory rate (RR) do respond lead to considerable sensitivity after about a day. Poorly to surgical stimulation (increases in BP, HR, and RR). adapted gingival margins develop microleakage, also causing2. Pain control through local anesthetic administration sensitivity. Preparation of the tooth itself can cause sensitiv- during surgery permits lessened exposure to general ity, through desiccation of tooth structure, possible pulpal anesthetic agents, allowing for a faster postanesthetic involvement, and periodontal irritation. The longer these recovery period and minimizing drug-related sources of irritation are present, the greater the trauma to complications. the tooth is likely to be, and the more difﬁcult it is to achieve3. Hemostasis is possible if a vasopressor is included. adequate anesthesia. Usually a regional nerve block is effec-4. Residual local anesthesia in the postoperative period tive. Supraperiosteal injections generally do not provide aids in postsurgical pain control. adequate pain control in these situations (depth may be The volume of drug and the rate at which it is adminis- adequate, but duration is considerably shorter than thattered are important in all areas of dental practice, but prob- usually expected from the drug).ably are most important during extraction of teeth frommultiple quadrants. When four third molars are extracted, LONG-DURATION LOCAL ANESTHESIAeffective pain control must be obtained in all four quadrants.This requires multiple injections of local anesthetics, which Prolonged Dental or Surgical Proceduresusually occur within a relatively short time. Four cartridges Several specialty areas of dental practice require longer thanor more of local anesthetic are frequently used.* The rate at usual pulpal or soft tissue anesthesia. They include ﬁxedwhich these local anesthetics are administered must be prosthodontics, oral surgery, and periodontics. Duringclosely monitored to lessen the occurrence of complications. longer procedures (2 or more hours), an adequate durationComplications arising from rapid administration of local of pulpal anesthesia may be difﬁcult to achieve with moreanesthetic include any of the following: commonly used anesthetics such as articaine, lidocaine,1. Pain during injection mepivacaine, and prilocaine. Bupivacaine is a long-acting2. Greater possibility of a serious overdose reaction, if the local anesthetic that can then be used. It is discussed more local anesthetic is administered intravascularly (the completely in Chapter 4. speed of IV drug administration signiﬁcantly affects the Bupivacaine, a homolog of mepivacaine, has a long dura- clinical manifestations of toxicity) tion of clinical effectiveness when used for regional nerve3. Postanesthetic pain caused by tissue trauma during the block. Its duration of action when administered by supra- injection periosteal injection, although still long, is somewhat shorter These complications and their prevention, recognition, (shorter even than that of lidocaine with epinephrine).48 Itsand management are discussed in greater detail in Chapters postoperative analgesic period lasts an average of 8 hours in17 and 18. the mandible and 5 hours in the maxilla. It should be noted that in some persons, the inferoposte- Bupivacaine is available with a vasopressor (1 : 200,000rior border of the mandible is not innervated by the trigemi- epinephrine). It is interesting to note that the addition ofnal nerve. Any of the mandibular nerve blocks described in vasopressor to bupivacaine does not prolong its duration of action.49*Typical local anesthetic injections for extraction of four third molars Postsurgical Management of Paininclude the following:1. Right and left inferior alveolar nerve blocks, 1.8 mL each (3.6 mL) Frequently, after extensive surgical procedures, patients2. Right and left posterior superior alveolar nerve blocks or supraperiosteal experience intense pain when the local anesthetic effect dis- inﬁltration over each third molar, 1.3 to 1.8 mL each (2.6 to 3.6 mL) sipates. It was, and still is in many cases, common practice3. Right and left palatal inﬁltration over the maxillary third molars, to treat postoperative pain through the use of opioid anal- 0.45 mL each, or right and left greater palatine nerve block, 0.45 mL each (0.09 mL) gesics. However, opioids have a high incidence of undesirableTotal volume of local anesthetic: 8.1 mL or 162 mg or a 2% solution, side effects such as nausea, vomiting, constipation, respira-243 mg of a 3%, or 324 mg of a 4%. tory depression, and postural hypotension, especially in
286 PART III Techniques of Regional Anesthesia in Dentistryambulatory patients.50 Additionally, opioid analgesics are notvery effective in the management of pain following dental TABLE 16-5surgery.51 Oxford League of Analgesic Efﬁcacy (Drugs Available Long-acting local anesthetics administered to surgical in the United States and Canada)*†patients offer a means of providing successful postopera- Patients with at leasttive pain control with minimal risk of developing adverse Analgesic & Dose (mg) NNT 50% pain reliefreactions. An advantage of using long-duration local anes- Ibuprofen 600/800 1.7 86thetics is their longer postoperative analgesia, which leads to Ketorolac 20 1.8 57a reduced need for the administration of postoperative Ketorolac 60 (IM) 1.8 56opioid analgesic drugs.52 Dentists often use an intermediate- Diclofenac 100 1.8 69acting local anesthetic such as articaine, lidocaine, mepiva- Piroxicam 40 1.9 80caine, or prilocaine with a vasopressor for the surgical Celecoxib 400 2.1 52 Paracetamol 1000 + 2.2 57procedure, administering a long-acting local anesthetic just Codeine 60before the termination of surgery. Danielsson and associates Oxycodone IR 5 + 2.2 60compared bupivacaine, etidocaine, and lidocaine with regard Paracetamol 500to their effects on postoperative pain, and found that both Oxycodone IR 15 2.3 73bupivacaine and etidocaine were more effective in control- Aspirin 1200 2.4 61ling postoperative pain when compared with lidocaine.48 Ibuprofen 400 2.4 55They also reported that bupivacaine was more effective than Oxycodone IR 10 + 2.7 67etidocaine in providing postoperative analgesia, and that Paracetamol 1000patients receiving bupivacaine used signiﬁcantly fewer Naproxen 400/440 2.7 51analgesics. Pirocicam 20 2.7 63 It is pertinent to note that there appears to be a difference Meperidine 100 (IM) 2.9 54between etidocaine and bupivacaine with respect to their Tramadol 150 2.9 48 Morphine 10 (IM) 2.9 50ability to provide adequate hemostasis, even though they Ketorolac 30 (IM) 3.4 53contain the same concentration of vasopressor (1 : 200,000). Placebo n/a 18Danielsson and associates noted that bupivacaine and lido-caine provided adequate hemostasis in 90% and etidocaine Modiﬁed from the Oxford League Table of Analgesics in Acute Pain, Bandolier Website, 2007. Available at: http://www.medicine.ox.ac.uk/in only 75% of procedures.49 It is possible that a higher con- bandolier/booth/painpag/acutrev/analgesics/leagtab.html. Accessed 6centration of local anesthetic may necessitate a higher con- October 2011.centration of vasopressor to provide comparable hemostasis. *Paracetamol is known as acetaminophen in the United States andAlso keep in mind the different vasodilating properties of the Canada. †solutions.53 Etidocaine HCl is no longer available in dental Intramuscular drugs (IM) are highlighted in red.cartridges in North America.Protocol for Perioperative and Postoperative Pain Control number needed to treat (NNT), the number of patientsin Surgical Patients. Postoperative pain associated with who need to receive the active drug for one to achieve atmost uncomplicated dental surgical procedures is mild and least 50% relief of pain compared with placebo over ais well managed by oral administration of nonsteroidal 4- to 6-hour treatment period.55 The most effective analge-anti-inﬂammatory drugs (NSAIDs) such as aspirin and sics have an NNT of just over 2 (Table 16-5). Effectiveibuprofen.51 Preoperative administration of NSAIDs appears pain relief for dental surgery normally can be achieved withto delay the onset of postoperative pain and to lessen its oral nonopioid, nonsteroidal anti-inﬂammatory drugs,severity.52,54 When a patient is unable to tolerate aspirin coxibs, and combinations of acetaminophen (paracetamol)or other NSAIDs, acetaminophen can provide acceptable and codeine.51analgesia. As noted in Table 16-5, few, if any, analgesics are better Other dental surgical procedures, such as removal of bony than NSAIDs for acute pain. All NSAIDs on the League tableimpactions and osseous periodontal or endodontic surgery, have NNTs of 1.6 to 3.0. Alternative analgesics, such asare more traumatic and typically are associated with more codeine 60 mg and tramadol 50 mg, have NNTs of 16 and 8,intense and prolonged postoperative pain. The onset of such respectively. Parenteral morphine 10 mg and meperidinepain can be delayed by presurgical administration of an 100 mg have NNTs of 2.9.51,56 Acetaminophen (paracetamol),NSAID followed by administration of a long-acting local administered orally at a dose of 1000 mg, has an NNT ofanesthetic (bupivacaine) at the completion of surgery.54 almost 4. When combined with codeine 60 mg, its NNT The Oxford League Table of Analgesic Efﬁcacy presents improves to 2.2. Ibuprofen 400 mg at 2.4 and diclofenaca meta-analysis of randomized, double-blind, single-dose, 50 mg and rofecoxib 50 mg at about 2.3 are better. NSAIDsplacebo-controlled studies in patients with moderate to generally do well with lower (better) NNTs.51severe postoperative dental, orthopedic, gynecologic, and For effective postsurgical pain management (i.e., nogeneral surgical pain.51 Analgesic efﬁcacy is expressed as breakthrough pain), it is important to maintain a therapeutic
CHAPTER 16 Anesthetic Considerations in Dental Specialties 287TABLE 16-6Nonsteroidal Anti-Inﬂammatory DrugsGeneric Proprietary Availabiity, mg Dosage RegimenIbuprofen Advil, Caldolor, 100, 200, 400, 600, 800 Adults: 400 mg PO every 4-6 hours as needed Motrin, and othersKetorolac Toradol 10 10 mg PO q4-6h; max 40 mg/day Start 20 mg PO if <65 yo and >50 kg Note: PO only for patients who have received parenteral treatment; duration of combined PO/IM/IV treatment not to exceed 5 daysDiclofenac Cambia, Zipsor 50 50 mg PO tid potassium Start 100 mg PO; 200 mg/day ﬁrst 24 hours only, 150 mg/day thereafterPiroxicam Feldene 10, 20 Adults: 20 mg PO once daily. Adjust dose, as needed. Daily dose may be divided into two doses, if desired.Celecoxib Celebrex 50, 100, 200, 400 Start 400 mg PO, then 200 mg PO bidNaproxen Naprosyn 250, 375, 500 250-500 mg PO q12h. Max: 1250 mg/dayTramadol Ultram, Ryzolt 50, 100, 200 ER 50-100 mg PO q4-6h; Max: 400 mg/dayData from Mosby’s dental drug reference, St Louis, 2012, Mosby. effective dose and shortest possible duration. Adolescents:BOX 16-2 Pain Control Regimen for 400 mg PO every 4–6 hours as needed. Doses greater than Surgical Procedures 400 mg have not provided greater relief of pain. Preoperative: Administer one oral dose of nonsteroidal anti-inﬂammatory drug (NSAID), minimally 1 hour Despite the statement above regarding larger doses than before the scheduled surgical procedure. 400 mg ibuprofen, the Oxford League clearly shows that ibu- Perioperative: Administer local anesthetic of adequate profen 600 mg (NNT of 1.7) is more efﬁcacious than ibu- duration for procedure (articaine, lidocaine, profen 400 mg (NNT of 2.4). mepivacaine, prilocaine with vasopressor). Box 16-2 outlines a recommended protocol for the man- If surgery of approximately 30 minutes’ duration is agement of intraoperative and postoperative pain associated planned, immediately follow initial local anesthetic injec- with dental surgical procedures.58 Common NSAIDs and tion with long-acting local anesthetic (bupivacaine). their recommended doses are listed in Table 16-6. If surgery of 1 hour or longer duration is planned, at the conclusion of the surgical procedure reinject the DENTAL HYGIENE patient with long-acting local anesthetic (bupivacaine). Postoperative: Have patient continue to take oral In 1997 when the fourth edition of this textbook was NSAID on a timed basis (e.g., bid, tid, qid) for the published, registered dental hygienists in 20 states in the number of days considered necessary by the United States and several provinces in Canada were permit- surgeon. ted to administer local anesthesia to dental patients. This Contact patient via telephone the evening of the number increased to 32 in 2003 and today (2011) stands at surgery to determine level of comfort. If considerable 44 states (Fig. 16-6).59 Inclusion of this expanded function pain is present, add opioid to NSAID: codeine. in the Dental Practice Act in these areas has proved of great beneﬁt to the hygienist, doctor, and dental patient.60,61Modiﬁed from Malamed SF: Local anesthetics: dentistry’s most important Though not all patients need local anesthesia for scaling,drugs, J Am Dent Assoc 125:1571–1576, 1994. root planing, and subgingival curettage, many do. The periodontal tissues being treated normally are sensitive to stimuli and are even more so when inﬂammation is present.blood level of the analgesic via time-based dosage adminis- Such is frequently the case when a patient is treated by thetration of the appropriate oral analgesic. A therapeutic dose dental hygienist.of the drug (e.g., ibuprofen 600 mg) should be administered The hygienist who is permitted to administer local anes-every 4 to 6 hours. The drug package insert for ibuprofen thetics to dental patients requires the same techniquestates the following regarding its administration for mild to armamentarium as the doctor. Regional block anesthesia,moderate dental pain57: especially in the maxilla (posterior superior or anterior supe- rior alveolar nerve block), is an integral part of the hygienist’s Oral dosage: Adults: 400 mg PO every 4–6 hours as needed. anesthetic armamentarium because hygienists usually treat Doses greater than 400 mg have not provided greater relief whole quadrants during a single appointment. The hygiene of pain. Elderly: See adult dosage; as elderly patients may patient requires the same depth of anesthesia as is attained be at a higher risk of adverse events, treat with the lowest by the doctor doing restorative dentistry or surgery. Root
288 PART III Techniques of Regional Anesthesia in Dentistry WA 1971 NH ME MT VT 2002 ND 1997 1985 1993 2003 OR MN MA 1975 ID 1995 2004 SD WI NY 1975 1992 1998 WV WY 2001 MI 2003 RI 1991 2002 CT 2005 IA *PA NE 1998 2005 NV OH NJ 1982 1995 IL *IN UT 2006 DE 2008 2000 2008 1983 CO *MD CA 1977 KS MO VA 1982 KY 2009 1993 1973 2006 2002 TN NC DC AZ OK 2004 2004 1976 NM AR SC 1972 1980 1995 1995 MS AL GA TX LA 1998 AK 1981 FL Local anesthesia Total jurisidictions 44 HI Revised June, 2009 1987 *Rules pending for IN, PA, and MD www.adha.org Figure 16-6. Dental Hygiene local anesthesia map.planing without discomfort requires pulpal anesthesia, along irreversible pulpitis, Oral Surg Oral Med Oral Pathol Oralwith soft tissue and osseous anesthesia.60 More than 70% of Radiol Endodont 84:676–682, 1997.respondents to a survey on dental hygiene patients’ need for 9. Leonard M: The efﬁcacy of an intraosseous injection systempain control reported that their patients needed anesthesia of delivering local anesthetic, J Am Dent Assoc 126:11–86,but did not receive it.61 1995. 10. Coury KA: Achieving profound anesthesia using the intraosse- Feedback from dentists whose hygienists administer local ous technique, Tex Dent J 114:34–39, 1997.anesthesia has been uniformly positive; negative comments 11. Nusstein J, Reader A, Nist R, et al: Anesthetic efﬁcacy of thehave been extremely rare.62 Dental patients themselves are supplemental intraosseous injection of 2% lidocaine withaware of the difference between local anesthesia adminis- 1:100,000 epinephrine in irreversible pulpitis, J Endodonttered by the dental hygienist and that administered by 24:478–491, 1998.the dentist. They frequently comment on the lack of dis- 12. Quinn CL: Injection techniques to anesthetize the difﬁcultcomfort when the hygienist injects the local anesthetic. Be tooth, J Calif Dent Assoc 26:665–667, 1998.it a slower rate of administration, greater attention to the 13. Parente SA, Anderson RW, Herman WW, et al: Anesthetic efﬁ-details of atraumatic injection technique, or greater empathy, cacy of the supplemental intraosseous injection for teeth withit works. irreversible pulpitis, J Endodont 24:826–828, 1998. 14. Brown R: Intraosseous anesthesia: a review, J Calif Dent Assoc 27:785–792, 1999.References 15. Weathers A Jr: Taking the mystery out of endodontics. Part 6. 1. Brown RD: The failure of local anaesthesia in acute inﬂamma- Painless anesthesia for the “hot” tooth, Dent Today 18:90–93, tion, Br Dent J 151:47–51, 1981. 1999. 2. Vandermeulen E: Pain perception, mechanisms of action of 16. Stabile P, Reader A, Gallatin E, et al: Anesthetic efﬁcacy and local anesthetics and possible causes of failure, Rev Belge heart rate effects of the intraosseous injection of 1.5% etido- Medecine Dent 55:19–40, 2000. caine (1:200,000 epinephrine) after an inferior alveolar nerve 3. Kitay D, Ferraro N, Sonis ST: Lateral pharyngeal space abscess block, Oral Surg Oral Med Oral Pathol Oral Radiol Endodont as a consequence of regional anesthesia, J Am Dent Assoc 89:407–411, 2000. 122:56–59, 1991. 17. Replogle K, Reader A, Nist R, et al: Cardiovascular effects of 4. Connor JP, Edelson JG: Needle tract infection: a case report, intraosseous injections of 2% lidocaine with 1:100,000 epi- Oral Surg 65:401–403, 1988. nephrine and 3% mepivacaine, J Am Dent Assoc 130:549–657, 5. Malamed SF: Buffering local aesthetics in dentistry, ADSA 1999. Pulse. In press. 18. Saadoun AP, Malamed SF: Intraseptal anesthesia in periodontal 6. Personal communication, Onpharma Inc., February 2011. surgery, J Am Dent Assoc 111:249-256, 1985. 7. Coggins R, Reader A, Nist R, et al: Anesthetic efﬁcacy of the 19. Goodsen JM, Moore PA: Life-threatening reactions after pedo- intraosseous injection in maxillary and mandibular teeth, Oral dontic sedation: an assessment of narcotic, local anesthetic, Surg Oral Med Oral Pathol Oral Radiol Endodont 81:634–641, and antiemetic drug interaction, J Am Dent Assoc 107:239– 1996. 245, 1983. 8. Reisman D, Reader A, Nist R, et al: Anesthetic efﬁcacy of the 20. Moore PA: Preventing local anesthesia toxicity, J Am Dent supplemental intraosseous injection of 3% mepivacaine in Assoc 123:60–64, 1992.
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