Post on 07-Apr-2022
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
LOCAL ANESTHESIA Update
Stanley F. Malamed, DDS Dentist Anesthesiologist
Emeritus Professor of Dentistry Ostrow School of Dentistry of USC
Los Angeles, California, USA
1
I have a relationship with the following companies that may be relevant to this presentation. I am a paid consultant to:
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Septodont, Inc OnPharma St. Renatus 3M ESPE
Stanley F. MALAMED, DDS Dentist Anesthesiologist
Emeritus Professor of Dentistry Ostrow School of Dentistry of USC
1
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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© 2014 Dr. Stanley F. MalamedAll Rights Reserved
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
LOCAL ANESTHETICS are the SAFEST and MOST EFFECTIVE
drugs in medicine for the PREVENTION & MANAGEMENT of pain
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Local Anesthetic Use in Dentistry
Annual LA usage (approximate)
300 x 106 USA (300,000,000) 80 x 106 Germany
40 x 106 U.K. Amides have been available since 1948
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Esters
Amides
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Lidocaine
1st AMIDE local anesthetic Introduced 1948
Astra Pharmaceuticals (SWEDEN)
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Lidocainewith
epinephrine 1: 50,000* 1: 80,000
1:100,000* 1:200,000 1:300,000
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• Duration of pulpal anesthesia = ~60 minutes
• Duration of soft tissue anesthesia = ~3 - 5 hours
Lidocaine 2% with vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Intermediate - Duration LA
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• Indicated for:• Dental therapy of approximately 45 - 60 minute duration
• Depth of pulpal anesthesia usually adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one or more quadrants
Lidocaine 2% with vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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Mepivacaine
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Mepivacaine3%
No vasoconstrictor
Mepivacaine2%
With vasoconstrictor
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• Duration of pulpal anesthesia (infiltration) = ~20 minutes
• Duration of pulpal anesthesia (nerve block) = ~40 minutes
• Duration of soft tissue anesthesia = ~2 - 3 hours
Mepivacaine 3% No vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Short - Duration LA
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• Indicated for:• Dental therapy of SHORT duration (~30 minutes)
• Depth of pulpal anesthesia MAY NOT be adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one quadrant only
Mepivacaine 3% No vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Mepivacainewith
epinephrine (Canada)
1:100,000
with levonordefrin (USA)
1: 20,000
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• Duration of pulpal anesthesia = ~60 minutes
• Duration of soft tissue anesthesia = ~2 - 3 hours
Mepivacaine 2% with vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Intermediate - Duration LA
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
• Indicated for:• Dental therapy of approximately 45 - 60 minute duration
• Depth of pulpal anesthesia usually adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one or more quadrants
Mepivacaine 2% with vasoconstrictor
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Prilocaine
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Prilocaine4%
No vasoconstrictor
Prilocaine3% or 4%
With vasoconstrictor
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• Duration of pulpal anesthesia (infiltration) = ~20 minutes
• Duration of pulpal anesthesia (nerve block) = ~40 - 60 minutes
• Duration of soft tissue anesthesia = ~2 - 3 hours
Prilocaine 4% No vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Short - Duration LA
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• Indicated for:• Dental therapy of SHORT duration (~30 minutes)
• Depth of pulpal anesthesia MAY NOT be adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one quadrant only
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Prilocaine 4% No vasoconstrictor
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• Not indicated for:• Appears to be associated with a higher risk of
paresthesia following IANB (see Pogrel 2007, 2012 JCDA)
• Depth of pulpal anesthesia MAY NOT be adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating more than one quadrant
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Prilocaine 4% No vasoconstrictor
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Prilocaine4% with
epinephrine1:200,000
3% with feltpressin
0.3 IU
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• Duration of pulpal anesthesia = ~60 minutes
• Duration of soft tissue anesthesia = ~3 - 8 hours
Prilocaine 3% or 4% with vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Intermediate - Duration LA
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
• Indicated for:• Dental therapy of approximately 45 - 60 minute duration
• Depth of pulpal anesthesia usually adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one or more quadrants
Prilocaine 3% or 4% with vasoconstrictor
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• Not indicated for:• Appears to be associated with a higher risk of
paresthesia following IANB (see Pogrel 2007, 2012 JCDA)
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Prilocaine 3% or 4% with vasoconstrictor
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Bupivacaine
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Bupivacaine0.5% with
epinephrine1:200,000
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• Duration of pulpal anesthesia = >90 minutes (nerve block)
• Duration of soft tissue anesthesia = ~5 - 12 hours
Bupivacaine 0.5% with vasoconstrictor
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Long - Duration LA
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• Indicated for:• Dental therapy of > 2 hour duration
• Post-surgical pain control
Bupivacaine 0.5% with vasoconstrictor
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• Not indicated for:• Rarely indicated for administration to children (long
duration soft tissue anesthesia = increased risk of self-inflicted soft tissue injury)
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Bupivacaine 0.5% with vasoconstrictor
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Articaine
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Articaine4% with
epinephrine1:100,000 1:200,000
• Synthesized in Germany 1973 • Introduced Germany 1976 • Canada 1985
1st & only Local anesthetic designed for dentistry
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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 1:100,000 & 200,000
100,000 200,000
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
33
• Indicated for:• Dental therapy of approximately 60 minute duration
• Depth of pulpal anesthesia usually adequate for pulpally-involved teeth
• Pediatric patients (< 30 kg) when treating one or more quadrants
Articaine 4% Epinephrine 1:100,000 & 200,000
100,000 200,000 © 2015 Dr. Stanley F. MalamedAll Rights Reserved
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• Indicated for:• Pregnant patients*
• Nursing mothers*
• Mandibular infiltration in adult patients*
Articaine 4% Epinephrine 1:100,000 & 200,000
100,000
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200,000
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• Indicated for:• Hemostasis
• 1:100,000 provides better hemostasis than 1:200,000
Articaine 4% Epinephrine 1:100,000
100,000
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36
• Should I use articaine 4% with 1:100,000 or 1:200,000 epineprine?
• Though BOTH epinephrine concentrations are SAFE in most patients, the lesser concentration (1:200,000) is preferred as there is NO clinical difference in either the DEPTH or DURATION of PAIN CONTROL.
Articaine 4% Epinephrine 1:100,000 & 200,000
100,000
200,000
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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• Should I use articaine 4% with 1:100,000 or 1:200,000 epineprine?
Articaine 4% Epinephrine 1:100,000 & 200,000
100,000
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
• For HEMOSTASIS during surgical procedures, small volumes of 1:100,000 epinephrine infiltrated is recommended.
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Local Anesthetics by EXPECTED duration of PULPAL anesthesia
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NormalDistribution
Curve
Bell-ShapedCurve
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Local Anesthetics by EXPECTED duration of PULPAL anesthesia
• Short-duration (~30 minutes)
• Mepivacaine 3%, Prilocaine 4%
• Intermediate-duration (~60 minutes)
• Articaine 4%, Lidocaine 2%, Mepivacaine 2%, Prilocaine 4% (all with vasoconstrictor)
• Long-duration (>90 minutes)
• Bupivacaine 0.5% (with vasoconstrictor) © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Maximum recommended therapeutic dosages
Drug Mg/kg Absolute maximum
Articaine HCl 7 n/a
Bupivacaine HCl *** 90
Lidocaine HCl 7 500
Mepivacaine HCl 6.6 400
Prilocaine HCl 8 600 © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Whats’s Newin
Local Anesthesia?
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Articaine - mandibular infiltration The LA ‘OFF’ switch The LA ‘ON’ switch Maxillary anesthesia without injection
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Articaine HCl by Mandibular Infiltration in Adults
Mandibular infiltration
John Meechan (UK)Al Reader (USA)
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ARTICAINE HCl
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© 2013 Dr. Stanley F. MalamedAll Rights Reserved
IA + a-caine infiltration
IA + a-caine infiltration
IA + dummy infiltration
IA + dummy infiltration
Anesthesia success >2 consecutive 80/80 readings
Failuren (%)
Successn (%)
Failuren (%)
Successn (%)
McNemar TestP-value
1st molar 3 (8.3) 33 (91.7) 16 (44.4) 20 (55.6) <0.001
Premolars 4 (11.1) 32 (88.9) 12 (33.3) 24 (66.7) 0.021
Lateral incisors
8 (22.2) 28 (77.8) 29 (80.6) 7 (19.4) <0.001
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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
1st Molar91.7%
55.6%
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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
1st Premolar88.9%
66.7%
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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
Lateral Incisor
77.8%
19.4%
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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL infiltration @ lateral incisor:
Central incisor: 94%
Mandibular incisorsARTICAINE HCl
Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL & LINGUAL infiltration @ lateral incisor:
Central incisor: 97%
Mandibular incisorsARTICAINE HCl
Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
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Mandibular incisors
Articaine B&L
Articaine B
Lidocaine B&L
Lidocaine B
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Phentolamine Mesylate
The local anesthetic “OFF SWITCH”
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PLAIN LAs provide a
SHORT-DURATION of
NOT VERY PROFOUND anesthesia
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To increase DURATION, and to increase DEPTH, of anesthesia, a VASOCONSTRICTOR is added to the LA solution
EpinephrineLevonordefrin
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FelypressinNorepinephrine
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Intermediate - duration LAs - USA
Articaine 4%Epi
1:100k1:200k 2 - 3 min 60 min 3 - 5 hours
Lidocaine 2%
Epi 1:50k, 1:100k 3 - 5 min 60 min 3 - 5 hours
Mepivacaine 2%
Levonordefrin 1:20k 3 - 5 min 60 min 3 - 5 hours
Prilocaine 4%
Epi 1:200k 3 - 5 min 60 min 3 - 8 hours
Drug Onset (textbook) Pulpal Soft Tissue
Epi = Epinephrine (Adrenalin) © 2015 Dr. Stanley F. MalamedAll Rights Reserved
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The PROBLEM, on occasion,
is RESIDUAL SOFT TISSUE ANESTHESIA
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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Age % with soft tissue
trauma< 4 years 18%4 - 7
years16%
8 - 11 years
13%12+ 7%
13% of pediatric patients receiving IANB suffer post-treatment traumatic injury to soft tissues.
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
College C, Feigal R, Wandera A, Strange M. Bilateral versus unilateral mandibular block anesthesia in a pediatric population. Pediatr Dent. 22(6):453-457, 2000.
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Phentolamine Mesylate
The local anesthetic “OFF SWITCH”
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Phentolamine mesylate is a vasodilator (an alpha adrenergic antagonist) that increases vascular perfusion in the area of injection.
This increased perfusion leads to an increased rate of the LA diffusing out of the nerve into the cardiovascular system, thereby decreasing the duration of residual soft tissue anesthesia.
Epinephrineconstricts blood vessel
Phentolamine dilates blood vessel
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Local Anesthesia Reversal
Does it work?60
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
YES! YES!
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1
1
UPPER&LIP
Control 133&minutesPM 50&minutes
Accelerated&by: 83&minutes
&&LOWER&LIP
Control 155&minutesPM 70&minutes
Accelerated&by: 85&minutes
Percep&on)of)normal)appearance)and)func&on)Accelerated&by&60&min.
Restora&on)of)normal)func&on)
Accelerated&by&60&min.
3
Restora&on)of)normal)sensa&on)of)tongue)
Accelerated&by&65&min.
4
Thanks to: Suzete Brasil, Erica Dicterow, Fariba Neumann & Joan Ong © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Conservative dental treatment Non-surgical periodontics (SRP)
Pediatric dentistry Medically compromised patients:
e.g.: Diabetics Geriatric patients Special needs patients Post-mandibular implants
Phentolamine MesylateOraVerse
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Buffered Local Anesthetics Alkalinized Local Anesthetics
The local anesthetic “ON SWITCH”
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How long does it take for pulpal anesthesia to develop?
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Articaine 4%Epi
1:100k1:200k 2 - 3 min 60 min 3 - 5 hours
Lidocaine 2%
Epi 1:50k, 1:100k 3 - 5 min 60 min 3 - 5 hours
Mepivacaine 2%
Levonordefrin 1:20k 3 - 5 min 60 min 3 - 5 hours
Prilocaine 4%
Epi 1:200k 3 - 5 min 60 min 3 - 8 hours
Drug Onset (textbook) Pulpal Soft Tissue
Epi = Epinephrine (Adrenalin)
Intermediate - duration LAs - USA
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How long does it REALLY take for pulpal anesthesia to develop?
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)
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#
Lai,#et#al,#so>#?ssue#v.#EPT#
70%
25%
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
At 4 minutes: 70% soft tissue numb 25% pulpal anesthesia
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Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)
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#
Lai,#et#al,#so>#?ssue#v.#EPT#
85%
40%
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)
At 6 minutes: 85% soft tissue numb 40% pulpal anesthesia
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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#
Lai,#et#al,#so>#?ssue#v.#EPT#
Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
OW!
30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)
70%
25%
85%
40%
70
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
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Most doctors wait ~10 minutes
At 10 minutes: 60% pulpal anesthesia
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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#
Many practitioners wait 15 minutes (67%)
N = 1078
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsAverage for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean
Some doctors wait ~15 minutes
At 15 minutes: 67% pulpal anesthesia
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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 © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Can we speed the onset of anesthesia . . .
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#
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
#Chaney#(1991)(m)(L)#
#Hinckley#(1991)(m)(L)#
#McLean#(1993)(m)(L)#
#Childers#(1996)(m)(L)#
#Dagher#(1997)(m)(L)#
#Goldberg#(2008)(m)(L)#
#Goodman#(2006)(m)(L)#
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
#Steinkruger#(2006)(m)(L)#
#Willet#(2008)(m)(L)#
#Vreeland#(1989)(m)(L)#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(L)#
#Hinckley#(1991)(m)(L)#
#McLean#(1993)(p)(L)#
#Dagher#(1997)(p)(L)#
#Goldberg#(2008)(p)(L)#
#Goodman#(2006)(p)(L)#
#Hannan#(1999)(p)(L)#
#Willet#(2008)(p)(L)#
with Articaine? © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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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#
30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine
Articaine
Lidocaine
N = 222
N = 1078
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
ARTICAINE + epinephrine
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Can we speed the onset of anesthesia
with Articaine?
NO © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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© 2014 Dr. Stanley F. MalamedAll Rights Reserved
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#
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
#Chaney#(1991)(m)(L)#
#Hinckley#(1991)(m)(L)#
#McLean#(1993)(m)(L)#
#Childers#(1996)(m)(L)#
#Dagher#(1997)(m)(L)#
#Goldberg#(2008)(m)(L)#
#Goodman#(2006)(m)(L)#
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
#Steinkruger#(2006)(m)(L)#
#Willet#(2008)(m)(L)#
#Vreeland#(1989)(m)(L)#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(L)#
#Hinckley#(1991)(m)(L)#
#McLean#(1993)(p)(L)#
#Dagher#(1997)(p)(L)#
#Goldberg#(2008)(p)(L)#
#Goodman#(2006)(p)(L)#
#Hannan#(1999)(p)(L)#
#Willet#(2008)(p)(L)#
by buffering the LA solution?
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Can we speed the onset of anesthesia . . .
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© 2014 Dr. Stanley F. MalamedAll Rights Reserved © 2013 Dr. Stanley F. Malamed
All Rights Reserved
© 2014 Dr. Stanley F. MalamedAll Rights Reserved
30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, ArticaineBuffered Lidocaine
67%N = 18
BUFFERED lidocaine + epinephrine
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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#
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by buffering the solution?
YES © 2015 Dr. Stanley F. Malamed
All Rights Reserved
Can we speed the onset of anesthesia
79
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Buffered Local Anesthetics
The local anesthetic “ON SWITCH”
Alkalinized Local Anesthetics
80
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Buffered Lidocaine by IANB
Pain Control Options
81
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
By INCREASING the pH of the local anesthetic solution from 3.5 to 7.35 we:
• Make the injection more comfortable• Increase the effectiveness of the LA• Dramatically decrease the onset time• Decrease postoperative ‘soreness’
82
Clinical Trial DataSummary
Malamed SF, Hersh E, Poorsattar S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11, 2013 © 2014 Dr. Stanley F. Malamed
All Rights Reserved
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6:37
1:51
© 2014 Dr. Stanley F. MalamedAll Rights Reserved
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FDA Approved for Lidocaine HCl
Lidocaine 2% + epinephrine 1:100,000 = pH 3.5BUFFERED
Lidocaine 1.75% + epi 1:125,000 + CO2 + NaHCO3 = pH 7.4
More dilute 6,000x more active ions to enter nerve
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
85
Onset treatment recommendations
1. Administer buffered lidocaine IANB 2. DO NOT LEAVE PATIENT !!! 3. You will know if your block is successful in 2 minutes 4. Check for pulpal anesthesia:
• EPT or Endo-Ice 5. In 2 minutes following
IANB begin tooth preparation © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
ARTICAINE
Pain Control Options
87
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
ArticaineUltracain
Septocaine Articadent Vivacaine Septanest
Alphacaine Zorcaine
88
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Articaine4% with
epinephrine1:100,000 1:200,000
• Synthesized in Germany 1973 • Introduced Germany 1976
1st & only Local anesthetic designed for dentistry
89
• 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 1:100,000 & 200,000
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
100,000 200,000
90
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
As sole injection by mandibular infiltration
Buccal infiltration - ARTICAINE
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Mandibular infiltrationJohn Meechan (UK)
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Al Reader (USA)
Buccal infiltration - ARTICAINE
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JADA 138(8):1104-1112, 2007
Articaine LidocaineMandibular 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
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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL infiltration @ lateral incisor:
Central incisor: 94%
Mandibular IncisorsARTICAINE HCl
Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
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Meechan & Ledvinka
1.0 mL Articaine 1:100k BUCCAL & LINGUAL infiltration @ lateral incisor:
Central incisor: 97%
Mandibular IncisorsARTICAINE HCl
Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002
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Mandibular Incisors
Articaine B&L
Articaine B
Lidocaine B&L
Lidocaine B
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Advantages1. Profound pulpal anesthesia2. 30 to 40 minute duration of plural anesthesia3. Minimal accessory soft tissue anesthesia
• Tongue
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
Buccal infiltration - ARTICAINE
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Disadvantage
I can’t think of any, unless it doesn’t work!
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Buccal infiltration - ARTICAINE
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Articaine infiltration as a supplement
to IANB
Pain Control Options
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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
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1st Molar91.7%
55.6%
Articaine infiltration as a supplement to IANB
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1st Premolar88.9%
66.7%
Articaine infiltration as a supplement to IANB
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Lateral Incisor
77.8%
19.4%
Articaine infiltration as a supplement to IANB
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Intranasal Local Anesthesiain the Maxilla
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Intranasal Local Anesthetic Mist
Intranasal Local Anesthetic Mist © 2015 Dr. Stanley F. MalamedAll Rights Reserved
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In mid-2015 in the USAwe will be able to administer
a local anesthetic intranasally to provide profound pulpal anesthesia
from #1.1 to 1.5 and 2.1 to 2.5(#4 to #13)
Intranasal Local Anesthetic Mist
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3% TetracaineEster-type local anestheticCommonly used by ENT surgeonsHas ‘track record’ as safe & effective IN
Intranasal Local Anesthetic Mist
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OxymetazolineVasoconstrictorActive ingredient in ‘Afrin’ & other nasal decongestants
Intranasal Local Anesthetic Mist
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3% TetracaineOxymetazoline
(active ingredient in Afrin nasal spray)
Sprayed into R & L naresN = 48
Intranasal Local Anesthetic Mist
Phase 2 clinical trial
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Injectable (lidocaine + epi)
94% success1st molar to 1st molar
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Palate
84% success 1st molar to 1st molar
100% successPremolar to premolar
Nasal Mist
16% failure on 1st molar © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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JADA 143(8):872-880, 2012
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Whats’s Newin
Local AnesthesiaIn the more distant future
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Optical control of pain-sensing neurons. QAQ selectively enters pain sensing neurons and
silences their activity (top, green light). Illumination with violet light (bottom) quickly restores signal
conduction
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
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Very Long-Acting
Analgesia
2014 DRUGS
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2014 DRUGS
Up to 72 hours
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Ultra Long-Acting
Analgesia
Neosaxitoxin
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One of a group of natural neurotoxic alkaloids,
commonly known as the paralytic shellfish toxins
(PSTs) © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Neosaxitoxin
Long-acting local ANESTHETIC Long-acting local ANALGESIC
• Chile & Harvard © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Neosaxitoxin
Over 1 week of analgesia (in rodents) without histologic or functional sequelae
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Now for a change of subject
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Everybody is different
We teach ‘normal’ anatomy: Insert the needle here Advance 25 mms Aspirate Deposit the drug We HOPE the nerve is in the area
A basic truism regarding ANATOMY:
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Once a needle penetrates the skin or mucous membrane,
every injection is BLIND
A basic truism regarding INJECTIONS:
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LAs are chemicals that interrupt nerve conduction
(producing anesthesia) transiently
(hopefully)
A basic truism regarding LOCAL ANESTHETICS:
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ALL LAs are neurotoxic (they can damage nerves)
Another truism regarding LOCAL ANESTHETICS
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
If all LAs were equally neurotoxic the % of cases of paresthesia would be
equal to the drugs % market share
50% of market share = 50% of cases of paresthesia25% of market share = 25% of cases of paresthesia
Ratio should be 1.0
% Cases of paresthesia% Market share
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Paresthesia has existed ever since injections
were first administered
A basic truism regarding PARESTHESIA:
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ARTICAINE © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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What, if any, are the clinical advantages of articaine HCl
compared with the other amide LAs?
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1. More lipid-solubleDiffuses through soft & hard tissues betterPalatal anesthesia with buccal infiltrationMandibular anesthesia in adults via infiltration
AdvantagesArticaine HCl
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Maxillary Infiltration
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Flared palatal roots Palatal soft tissue
Articaine Articaine
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Mandibular infiltrationJohn Meechan (UK)
Al Reader (USA)
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Articaine HCl by Mandibular Infiltration in Adults
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2. Elimination half-life of 27 minutes (162 min = 2:42) Lidocaine, mepivacaine, prilocaine ~ 90 minutes (540 min = 9 hrs)
AdvantagesArticaine HCl
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3. PregnancyAll other amide local anesthetics
Beta half-life ~90 minutes +
ARTICAINE
Beta half-life 27 minutes
AdvantagesArticaine HCl
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AdvantagesArticaine HCl
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
4. Nursing All other local anesthetics
Pump & discard for 9 hours*
ARTICAINE
Pump & discard for 4 hours*
USA FDA
USA FDA
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5. Pediatrics - preferred LA Decreased risk of overdose
Elimination half-life of 27 minutes
AdvantagesArticaine HCl
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Articaine is the LEAST LIKELY anesthetic to induce an overdose caused by administration of too many cartridges
© 2015 Dr. Stanley F. MalamedAll Rights Reserved
AdvantagesArticaine HCl
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6. Endodontics (infected / inflammed teeth)Greater lipid-solubility
Thiophene ring = articaineBenzene ring = other LAs
AdvantagesArticaine HCl
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Benzene ring = LIPID SOLUBILITY
= LIPID SOLUBILITYArticaine
LidocaineMepivacaine
PrilocaineBupivacaine
Thiophene ring
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7. ‘Hard to ‘numb’ patients (anecdotal)
AdvantagesArticaine HCl
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1. More lipid-solubleDiffuses through soft& hard tissues betterPalatal anesthesia with buccal infiltrationMandibular anesthesia in adults via infiltration
2. Elimination half-life of 27 minutes (162 min = 2:42) Lidocaine, mepivacaine, prilocaine ~ 90 minutes (540 min = 9 hrs)
3. Pregnancy - preferred LA4. Nursing - ‘Pump & dump’ for 4 hours (FDA)
Lidocaine, mepivacaine, prilocaine P&D for 9 hours5. Pediatrics - Lesser risk of OD6. Endodontics (infected/inflammed teeth)7. ‘Hard to ‘numb’ patients (anecdotal)
AdvantagesArticaine HCl
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So, Malamed, you think articaine is a
great drug, but . . .
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Are there any concerns,out there in the community,
regarding articaine HCl?
YESProlonged anesthesia
(paresthesia) © 2015 Dr. Stanley F. Malamed
All Rights Reserved
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Articaine and
Paresthesia
Just the Facts
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Haas, D A. Lennon, D.A 21 year retrospective study of reports of paresthesia
following local anesthetic administration.J. Canadian Dental Association). 61(4):319-20, 323-6, 329-30, 1995
Overall incidence of paresthesia (all LAs) = 1:785,000
2% and 3% LAs = 1:1,250,000
4% prilocaine = 1:588,235
4% articaine = 1:440,529 (0.000000227%) (2.2699e-06)
Ontario, Canada
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Mepivacaine 1:623,112,900
Lidocaine 1:181,076,673
Bupivacaine 1:124,286,050
OVERALL 1:13,800,970
Articaine 1:4,159,848
Prilocaine 1:2,070,678
USA
(0.000000024%)(2.403934e-07)
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Pogrel MAJ. Calif Dent Assoc 40:795-797, 2012 (October)
2012
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2007 2012
Lidocaine 0.64 0.5
Articaine 1.19 0.97
Mepivacaine 2.2
Prilocaine 4.96 3.25
M. Anthony Pogrel, DDS, MD
1.0 is expected
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Author Country Year %Lingual
Haas, Lennon Canada 1995 70.6
Hillerup Denmark 2006 77
Kingon, Sambrook Australia 2011 80
Garristo, Haas USA 2010 92.7
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So, why is it that the lingual nerve is primarily involved in cases of
paresthesia?
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“The Lingual Nerve is In the Way”
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IMO . . . IF it’s the distribution of the lingual nerve (loss of taste, paresthesia) . . .
It’s MECHANICAL
Not chemical
Professor Dr. Stanley F. Malamed
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Paresthesia in dentistry
> 95% of reported cases occur in the MANDIBLE
Of these the overwhelming percentage involve only the lingual nerve
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Is rarely observed in the maxilla< 5%Yet 1/2 of all dental care is in the upper arch
Paresthesia in dentistry
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Is rarely (no reported cases) observed following:
Gow-Gates mandibular nerve block
Vazirani-Akinosi mandibular nerve block
Only occasionally following mental/incisive nerve block
No lingual nerve in area
Paresthesia in dentistry
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Articaine is used in medicine:NO reports of paresthesia from articaine following use in medicine
Paresthesia and 4% Anesthetics
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Question:
Is it possible that articaine is so specifically neurotoxic that it only affects nerves within the mouth and more specifically the lingual nerve?
Answer:
NO !
Paresthesia and 4% Anesthetics
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So, what should YOU do?
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The doctor MUST always consider the BENEFIT to be gained from use of a procedure or drug versus the RISK involved in the procedure or drug.
ONLY when the benefit to be gained CLEARLY OUTWEIGHS the risk should the procedure be done or the drug administered
Benefit v. Risk
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ALL reports claiming an increased risk of paresthesia with articaine are
ANECDOTAL
There is absolutely NO scientific evidence articaine has a greater risk
of paresthesia than other LAs
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So, what should YOU do?
Continue to use Articaine by IANB blockIF you are unconvinced:
Use Lidocaine or Mepivacaine for IANBNOT Prilocaine
Follow Lidocaine IANB with Articaine buccal infiltrationAt apex of tooth being treated½ cartridge
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So, what should YOU do?
Continue to use Articaine by IANB block
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© 2015 Dr. Stanley F. MalamedAll Rights Reserved
So, what should YOU do?
IF you are unconvinced:Use Lidocaine or Mepivacaine for IANB
NOT PrilocaineFollow Lidocaine IANB with Articaine buccal infiltration
At apex of tooth being treated½ cartridge
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LOCAL ANESTHESIA Update
Stanley F. Malamed, DDS Dentist Anesthesiologist
Emeritus Professor of Dentistry Ostrow School of Dentistry of USC
Los Angeles, California, USA
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Thank you for listening . . .
malamed@usc.edu
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