1. NODC - IANB - title · during dental treatment? 6 ... patient loses consciousness General...

© 2018 D

r. Stanley F. Malam

edA

ll Rights R

eserved

Is the “M

andibular Block” Passé?

© 2018 Dr. Stanley F. MalamedAll Rights Reserved

Stanley F. Malamed, DDSDentist Anesthesiologist

Emeritus Professor of Dentistry Herman Ostrow School of Dentistry of U.S.C.

Los Angeles, CA, USA

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I have a relationship with the following companies that may be relevant to this presentation. I am a consultant to:

Stanley F. MALAMED, DDS Emeritus Professor of Dentistry

Herman Ostrow School of Dentistry of USC

Septodont, Inc

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[email protected]

[email protected] [email protected]


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2. Does not hurt 1. A painless injection

de St. Georges J. Dentistry Today 23(8): 96-99, August 2004

How Dentists Are Judged By Patients


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How can we PREVENT pain

during dental treatment?

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General Anesthesia

Local Anesthesia

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General Anesthesia

GA requires administration of CNS-depressant drugs until the

patient loses consciousness

General anesthesia represents the controlled

loss of consciousness


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© 2018 Dr. Stanley F. MalamedAll Rights Reserved © 2014 Dr. Stanley F. Malamed

All Rights Reserved

LOCAL ANESTHETICS are the only drugs that actually

PREVENT PAIN


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LOCAL ANESTHETICS are the SAFEST* and MOST EFFECTIVE

drugs in medicine for the PREVENTION & MANAGEMENT

of pain

* when used properly © 2018 Dr. Stanley F. Malamed

All Rights Reserved

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Localanesthetic LA

When a local anesthetic is deposited near a nerve it must diffuse across the nerve membrane INTO the nerve to block nerve conduction

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Local anesthetics

Lidocaine

Articaine

MepivacainePrilocaine

Bupivacaine


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Dentistry’s Most Important Drugs

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Annual LA usage - WORLDWIDE Dentistry

Lidocaine - 1,000,000,000 (estimated) Articaine - 600,000,000

Mepivacaine - 300,000,000 Prilocaine - 50,000,000

Bupivacaine - 10,000,000

Dentistry’s Most Important Drugs

1,960,000,000

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Short-duration (~30 minutes)

• Mepivacaine 3%, Prilocaine 4%

Intermediate-duration (~60 minutes)

• Articaine 4%, Lidocaine 2%, Mepivacaine 2%, Prilocaine 3% or 4% (all with vasoconstrictor)

Long-duration (>90 minutes)

• Bupivacaine 0.5% (with vasoconstrictor)

Local Anesthetics by EXPECTED duration of PULPAL anesthesia


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Deposit a Local Anesthetic Close to a

Nerve and It WILL

Produce Pain Control

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Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic. Stomatologiia. 85(6):6-10, 2006

How often do you encounter inefficiency of local anesthesia, both infiltration and conduction, during manipulation of various tooth groups?

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Tooth group Often Sometimes Rarely Very Rarely Never

Maxillary Incisors 1 3 17 37 3

Maxillary Canines 1 2 23 42 53

Maxillary Premolars 1 8 29 40 43

Maxillary Molars 1 19 31 41 29

Mandibular Incisors 4 6 17 39 55

Mandibular Canines 4 10 23 39 45

Mandibular Premolars 8 29 18 41 25

Mandibular Molars 20 47 32 21 1

Stiagailo SV. Local anesthesia failure problems in conservative dental therapy clinic.

Stomatologiia. 2006, 85(6):6-10

N = 121

16%

31%

55%


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Maxillary Incisors 1 3 17 37 3

Maxillary Canines 1 2 23 42 53

Maxillary Premolars 1 8 29 40 43

Maxillary Molars 1 19 31 41 29





N = 121

16%



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Why is there a discrepancy in success between the maxillary &

mandibular arches?Maxillary bone = thin = INFILTRATION

Mandibular bone = thick = NERVE BLOCK

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N = 121

31%

55%



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Anesthesia of Mandibular Premolars,

Canine, and Incisors,

can be (usually) easily accomplished

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V3

Foramen Ovale

Inferior alveolar n.

Mandibular n.

Mental n.

Incisive n.


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Incisive nerve block

Mental nerve block

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Needle: 27 gauge shortInsertion: MB fold at or anterior to

mental foramenTarget: Mental nerve as it exits

mental foramenVolume: 0.6 mLAspiration: 5.7%

aka Mental NB (incorrectly)

Incisive NB25


Insert needle in buccal fold and advance towards mental foramen

AspirateDeposit 0.6 mL outside foramen


Incisive NB26


VAS = 0 -2

Apply finger pressure for 2 minutes


Incisive NB27


Visual Analog ScaleVAS

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N = 121

55%



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The traditional ‘Mandibular Block’ has amongst the LOWEST success rates

of all major nerve blocks in the human body

Mandibular anesthesia30


A dentist will administer approximately 30,000 IANBs in the course of a 20-year career

Pogrel MA, Thamby S. Permanent nerve involvement resulting from

inferior alveolar nerve blocks JADA 2000;131:901-907

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A second problem with mandibular anesthesia, in the adult, is the lack of consistent landmarks.

Lack of consistent anatomy

Mandibular anesthesia

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Once a needle penetrates the skin or mucous membrane,

every injection is BLIND

A basic truism regarding INJECTIONS:33


Inferior Alveolar NB “Mandibular NB”

Inferior Dental Block

The traditional . . . .

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Inferior Alveolar NB“Mandibular NB”


The ‘HALSTED Approach’

William Stewart Halsted 1852-1922

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Needle: 25- or 27- gauge longInsertion: soft tissue on medial

border of mandibular ramusTarget: IA nerve on lingual aspect of

ramus prior to entering mandibular foramen

Volume: 1.5 - 1.8 mLAspiration: 10% - 15%

Inferior Alveolar Nerve Block“Mandibular NB”


VAS = 1 - 5

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Immediately following completion of IANB . . .to obtain

“COMPLETE ANESTHESIA” of the quadrant

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Needle: 25- or 27- gauge longInsertion: mucus membrane distal and

buccal to last mandibular molarTarget: buccal nerve passing over

border of ramusVolume: 0.2 - 0.3 mLAspiration: 0.7%

Buccal NB“Long” Buccal

VAS = 5 - 8

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Following completion of IANB & Buccal NBs . . .

Seat patient comfortably upright

Speeds onset of anesthesia

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FAINTING (syncope)

is the most common medical emergency in dentistry


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FAINTING (syncope)

most often occurs DURING or immediately AFTER the

injection of local anesthetic © 2018 Dr. Stanley F. Malamed

All Rights Reserved

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FAINTING (syncope)

is treated by increasing blood flow to the brain


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The experienced dentist administered the IANB by ‘feel’

Needle is advanced towards lingual aspect of body of mandible until bone is contacted.

Dr. ‘feels’ or ‘senses’ that the needle has contacted bone at the appropriate depth (based on years of clinical experience)



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The most common reason for missing the IANB is depositing LA solution too low. (BELOW the mandibular foramen)

The ‘nerve’ is gone! A little higher is a little better



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The Importance of AspiratingBefore and

DuringALL injections


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VAS = 1 - 5

Needle: 25- or 27- gauge longInsertion: soft tissue on medial border

of mandibular ramusTarget: IA nerve on lingual aspect of

ramus prior to entering mandibular foramen

Volume: 1.5 - 1.8 mL

Aspiration: 10% - 15%Aspiration: 10% - 15%

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Neurovascular bundle

Nerve

Artery

Vein

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What happens if a needle touches an

ARTERY? © 2018 Dr. Stanley F. Malamed

All Rights Reserved

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Facial artery

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The importance of contacting bone in the

inferior alveolar nerve block


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Facial (VII cranial nerve) nerve paralysis

Cause: Introduction of local anesthetic into capsule of parotid gland during inferior alveolar nerve block

Parotid gland

VII


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Depositing LA anywhere along the IA nerve will produce pain control

Inferior Alveolar Nerve Block

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Can we improve the success rate of

mandibular anesthesia ?

So the question is:53

Gow-Gates Mandibular Nerve Block

Vazirani - Akinosi (closed mouth) Mandibular Nerve Block

Periodontal ligament injection (intraligamentary)

Intraosseous anesthesia

Articaine HCl via buccal infiltration

Buffered local anesthetics

Possible Alternatives to the IANB


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TheGOW-GATES

Mandibular Nerve Block

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1973 . . . Gow-Gates Mandibular Nerve Block

1973

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George Gow-GatesWestmead Hospital, Sydney - 1993

If a little higher is a little better,a lot higher is a lot better

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The GOW-GATES MANDIBULAR NERVE BLOCK is the only true

mandibular (3rd division, V3) nerve block

Gow-Gates Mandibular Nerve Block59


AnesthesiaMandibular teeth to midlineBuccal soft tissues to midlineAnterior 2/3 of tongue and floor of oral cavityLingual soft tissues and periosteumBody of mandible, inferior portion of ramusSkin over zygoma, posterior portion of cheek, and temporal region



Needle: 25 gauge longInsertion: At height of ML cusp of

maxillary 2nd molar, just distal to 2nd molar

Target: Lateral aspect of condylar neck

Volume: 2.2 to 3.0 mL***Aspiration: < 2%

*** as per Dr Gow-Gates



A LOW Gow-Gatesis still a

HIGH IANB

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TheVazirani-Akinosi

(closed mouth)Mandibular Nerve Block

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Vazirani-Akinosi Nerve Block


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Akinosi-Vazirani Nerve Block




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1982 . . . Periodontal Ligament Injection (PDL) aka Intraligamentary Injection (ILI)

JADA October 1, 1981 103(4): 571-575

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27 gauge short needle

Place interproximally

SLOWLY deposit 0.2 mL per root

Periodontal Ligament Injection (PDL, ILI)69


27 gauge short needle

Place interproximally

SLOWLY deposit 0.2 mL per root

Periodontal Ligament Injection (PDL, ILI)

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In presence of PERIAPICAL infection:

PDL is not contraindicated, but may not be effective



Contraindication



1980’s . . .

Intraosseous Anesthesia (IO)

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1980’s . . . Intraosseous Anesthesia (IO)

Leonard M, J Amer Dent Assoc October 103(4): 571-575, 1981

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Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2%

lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endodont 24(7):487-491, 1998

88% successful mandibular molars

Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for

teeth with irreversible pulpitis. J Endodont 24(12):826-828, 1998

91% successful mandibular molars

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The guide sleeve remains inplace until you are sure youhave adequate anesthesia.

X-Tip


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ADVANTAGESRelatively comfortable

Single / multiple tooth anesthesiaNo lip / tongue


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DISADVANTAGESHighly vascular region

LA ODVasopressor “shakes” or tremor

use 1:200k or plainCan’t locate hole with needle


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1980’s . . .

Intraseptal Anesthesia

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Intraseptal (Crestal) Anesthesia

J Dent Res Dent Clin Dent Prospect.Winter 2011 5(1): 17-22, 2011

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Intraseptal (Crestal) Anesthesia 82



Crestal IANB

Onset 7.00 +/- 0.71

3.30 +/- 0.67

<0.001

Duration 23.10 +/- 2.13

32.10 +/- 2.02

<0.05

Pain 1.54 +/- 0.18

3.44 +/- 0.22

<0.001

Volume 0.4 mL +/- 2.07 1.99 mL

Intraseptal (Crestal) Anesthesia 83


Intraseptal (Crestal) Anesthesia


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4% with epinephrine

1:100,000 1:200,000

• Synthesized in Germany 1969 • Introduced Germany 1976 • Canada 1985 • USA 2000 • Australia 2005

1st & only Local anesthetic designed for dentistry

Articaine85


• Duration of pulpal anesthesia (infiltration) = 60 minutes

• Duration of pulpal anesthesia (nerve block) = 60 minutes

• Duration of soft tissue anesthesia = 3 - 5 hours

Articaine 4% Epinephrine

100,000 200,000

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Articaine infiltration as a sole injection

for mandibular anesthesia

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JADA 138(8):1104-1112, 2007

Articaine Lidocaine

Mandibular 2nd Molar 75% 45%

Mandibular 1st Molar 87% 57%

Mandibular 2nd Premolar 92% 67%

Mandibular 1st Premolar 86% 61%

p value for all: >.0001

Pulp test every 3 min

SUCCESS = 80/80 on 2

consecutive tests

Results -1:2007

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Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections.

Int Endod J 35:629-634, 2002

Mandibular Incisors2002

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Infiltration buccal fold by lateral incisor • 94% articaine; 70% lidocaine

Infiltration buccal & lingual by lateral incisor • 97% articaine; 88% lidocaine

Results-1:

Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of

infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002

2002

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>70% = 10 min>80% = 10 min>80% = 25 min>90% = 25 min


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Meechan JG, Ledvinka JI. Pulpal anaesthesia for mandibular central incisor teeth: a comparison of

infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002

Mandibular Incisors

2002

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Advantages1. Profound pulpal anesthesia2. 30 to 40 minute duration of pulpal anesthesia3. Minimal accessory soft tissue anesthesia

• Tongue

Buccal infiltration - ARTICAINE

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DisadvantageJust like maxillary infiltration,

I can’t think of any, unless it doesn’t work!

Buccal infiltration - ARTICAINE

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Articaine infiltration as a supplement

to IANB

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Kanaa JM, Whitworth JM, Corbett IP, Meechan JGArticaine buccal infiltration enhances the effectiveness of

lidocaine inferior alveolar nerve block.Int Endodont J 42:238-246, 2009 © 2018 Dr. Stanley F. Malamed

All Rights Reserved

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88.9%

66.7%

1st PremolarArticaine infiltration

as a supplement to IANB

88.9%


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91.7%

55.6%

1st MolarArticaine infiltration

as a supplement to IANB


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Buffered Local

Anesthetics

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Can we speed the onset of anesthesia . . .

by buffering the LA solution?

by changing the pH of the LA solution?

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pH ‘Plain’ LA solution = ~6.5 Vasoconstrictor LA solution = ~3.5 Articaine + épi = 5.2 Lemon juice concentrate = 3.3

pH of Local Anesthetics


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0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#

Lidocaine#IANB#Mean#

30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsAverage for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean

N = 1078

Most doctorswait ~10 minutes

At 10 minutes:60% pulpal anesthesia

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Why?

Six-Hour Time Course for Pulpal Analgesia (EPT) IANB Second Premolar

95% ofpatients will

(eventually) get numb

if given a 45-minute

waiting period

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IANB: Lidocaine + epinephrine

% clinically effective pulpal anesthesia• 25% at 4 minutes• 40% at 6 minutes

• 60% at 10 minutes• 67% at 15 minutes• 95% at 45 minutes

LidocaineN = 1078

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0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#

Ar/caine#IANB#Mean#

Lidocaine#IANB#Mean#

#Buffered#Lido#IANB#

67%

30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine

Buffered Lidocaine

ArticaineN = 222

LidocaineN = 1078

Buffered Lidocaine

N = 18

LIDOCAINE + EPI 1:100ARTICAINE + EPI 1:100

BUFFERED LIDOCAINE + EPI 1:100

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6:37

1:51



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(1) More comfortable injection for patient pH of anesthetic ~7.6

(2) More rapid onset on pulpal anesthesia(3) More profound anesthesia(4) Less post-injection soreness

(5) No effect on duration of action(6) No increase in LA blood level (safety)

When buffering is done properly the following advantages can be expected from the increase in pH:

Buffered Local Anesthetics


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Buffered LA

1. Administer buffered LA IANB 2. DO NOT LEAVE THE PATIENT !!! 3. You know if your block is successful in 2 minutes

Mandibular anesthesia - IANB

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4. Check for pulpal anesthesia: • EPT or Endo-Ice

5. In 2 minutes following IANB either begin tooth preparation or readminister LA

Buffered LAMandibular anesthesia - IANB

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Is the“MANDIBULAR

NERVE BLOCK”Passé ?

So . . .110


Options:

Incisive (mental) nerve block Gow-Gates mandibular nerve block Akinosi-Vazirani nerve block PDL, Intraosseous, Intraseptal Articaine by mandibular infiltration Buffered local anesthetic

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Incisive (mental) NB (Buffered) lidocaine, articaine, mepivacaine, prilocaine

0.6 - 0.9 mL

RecommendationPremolars and Canine and Incisors


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Infiltration of buffered articaine 0.6 - 0.9 mL buccal fold for ~10 minute treatment

RecommendationCanine or Incisor

Infiltration of buffered articaine 0.6 - 0.9 mL buccal AND lingual for 15 - 30 minute treatment, or . . .

Infiltration of buffered articaine 0.6 mL buccal fold and REPEAT if needed


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IANB or GGMNB utilizing (Buffered) lidocaine, articaine, mepivacaine, followed by (Buffered) articaine buccal infiltration at apex of tooth 0.6 - 0.9 mL

RecommendationPosterior teeth


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Is the“MANDIBULAR

NERVE BLOCK”Passé ?

So . . .

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Is the “Mandibular Block”

Passé?

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[email protected]

THANK YOU for LISTENING!

THANK YOU for LISTENING!


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1. NODC - IANB - title · during dental treatment? 6 ... patient loses consciousness General...

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