2015 Dr. Stanley F. Malamed

Transcription

Local Anesthesia
© 2015
© 2013
Dr. Stanley F. Malamed
All Rights
Reserved
All Rights Reserved
PAIN
© 2015 Dr. Stanley F. Malamed
All Rights Reserved
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PAIN
The greatest fear
dental patients have
is FEAR of PAIN
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Painless Injections
How Dentists Are Judged By Patients
How important
- to the patient is pain-free dental treatment?
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2. Does not hurt
1. A painless injection
de St. Georges J. Dentistry Today 23(8): 96-99, August 2004
© 2015
All2013
Rights
Reserved
©
Dr. Stanley
F. Malamed
All Rights Reserved
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LOCAL ANESTHETICS are the
SAFEST and MOST EFFECTIVE
drugs in medicine for the
PREVENTION & MANAGEMENT of pain
LOCAL ANESTHETICS
are the only drugs that actually
PREVENT PAIN
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Cocaine
Tetracaine
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AMIDES
ESTERS
Procaine
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1948
Articaine
Stanley F. Malamed, DDS
Bupivacaine
Dentist Anesthesiologist
Emeritus Professor of Dentistry
Ostrow School of Dentistry of U.S.C.
Los Angeles, CA, USA
Lidocaine
Benzocaine
Mepivacaine
Chloroprocaine
Prilocaine
Propoxycaine
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Local anesthetics What Local Anesthetics
are available in
(Dentistry)
Articaine
Dentistry Worldwide?
Bupivacaine
Lidocaine
Mepivacaine
Prilocaine
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What Local Anesthetics
Local anesthetics are available in
(Spain)
Articaine
SPAIN?
Bupivacaine
Lidocaine
Mepivacaine
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Local Anesthetics by
EXPECTED duration of PULPAL anesthesia
By MARKET SHARE
SPAIN
USA
Articaine
Lidocaine
Lidocaine
Articaine
Mepivacaine
Mepivacaine
Bupivacaine
Prilocaine
Normal
Distribution
Curve
BellShaped
Curve
Bupivacaine
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•
Cocaine
Mepivacaine 3%, Prilocaine 4%
Intermediate-duration (~60 minutes)
•
•
Blood flow through area is INCREASED
Short-duration (~30 minutes)
•
•
All injectable local anesthetics are VASODILATORS
Articaine 4%, Lidocaine 2%, Mepivacaine 2%,
Prilocaine 3% or 4% (all with vasoconstrictor)
Long-duration (>90 minutes)
•
Bupivacaine 0.5% (with vasoconstrictor)
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LA diffuses OUT of AREA more rapidly
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ESPAÑA
Short - Duration LAs
A
SPAIN
PLAIN LAs
provide a
SHORT-DURATION
of
NOT AS PROFOUND
anesthesia
~ 30 minutes
Mepivacaine
3%
No vasoconstrictor
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©All
2013
Rights
Dr. Stanley
Reserved
F. Malamed
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Short - duration LAs
To increase DURATION, and
to increase DEPTH, of anesthesia,
Drug
Onset (textbook)
Mepivacaine
3 - 5 min
3%
Pulpal
Soft Tissue
20 - 40 min 2 - 3 hours
infiltration - NB
ESPAÑA
a VASOCONSTRICTOR is added to the LA solution
USA
Worldwide
Epinephrine
Levonordefrin
Epinephrine
Norepinephrine
Felypressin
SPAIN
A
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© 2015
©All
2013
Rights
Dr. Stanley
Reserved
F. Malamed
All Rights Reserved
28
ESPAÑA
Intermediate - Duration LAs
A
SPAIN
~ 60 minutes
Articaine
4% + vasoconstrictor
Lidocaine
Mepivacaine
Through addition of a vasoconstrictor, the
ensuing BLOOD LEVEL of the local
anesthetic is significantly decreased,
making the LA drug SAFER by minimizing
risk of overdose (toxic reaction)
Epinephrine
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Local Anesthetic Blood Levels
MEPIVACAINE
•
5 mg/kg - NO epinephrine - PEAK LEVEL 1.2 ug/mL
•
•
•
5 mg/kg - Epi 1:200,000 - PEAK LEVEL 0.7 ug/mL
LIDOCAINE
•
400 mg - NO epinephrine - PEAK LEVEL 2.0 ug/mL
•
400 mg - Epi 1:200,000 - PEAK LEVEL 1.0 ug/mL
Prilocaine 4% (all with vasoconstrictor)
Approximately 90% of all local anesthetics
used by North American dentists are
intermediate-duration drugs
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Long - Duration LAs
Long - duration LAs
> 90 minutes
Drug
Bupivacaine
Bupivacaine
0.5%
0.5% + vasoconstrictor
ESPAÑA
SPAIN
A
Epi
1:200k
Onset (textbook)
Pulpal
Soft Tissue
6 -10 min
60 - 180
infiltration - NB
up to 12
hours
(up to 7 hours)
ESPAÑA
SPAIN
A
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SELECTION CRITERIA
Lidocaine
for
LOCAL ANESTHETICS
1st AMIDE local anesthetic
Introduced 1948
Astra Pharmaceuticals (SWEDEN)
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Lidocaine 2% with vasoconstrictor
Lidocaine
with
epinephrine
Intermediate - Duration LA
1: 50,000
1: 80,000*
1:100,000
1:200,000
1:300,000
•
Duration of pulpal anesthesia = ~60 minutes
•
Duration of soft tissue anesthesia = ~3 - 5 hours
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Lidocaine 2% with vasoconstrictor
•
Indicated for:
•
Dental therapy of approximately 45 - 60 minute duration
•
Depth of pulpal anesthesia usually adequate for pulpallyinvolved teeth
•
Pediatric patients (< 30 kg) when treating one or more
quadrants
Mepivacaine
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Mepivacaine 3% No vasoconstrictor
Mepivacaine
3%
No vasoconstrictor
Short - Duration LA
Mepivacaine
2%
With vasoconstrictor
•
Duration of pulpal anesthesia (infiltration) = ~20 minutes
•
Duration of pulpal anesthesia (nerve block) = ~40 minutes
•
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Mepivacaine 3% No vasoconstrictor
•
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
with
epinephrine
1:100,000
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Mepivacaine 2% with vasoconstrictor
Mepivacaine 2% with vasoconstrictor
•
Intermediate - Duration LA
•
Duration of pulpal anesthesia = ~60 minutes
•
Indicated for:
•
Dental therapy of approximately 45 - 60 minute duration
•
•
quadrants
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Bupivacaine
Bupivacaine
0.5% with
epinephrine
1:200,000
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Bupivacaine 0.5% with vasoconstrictor
•
Not indicated for:
•
Long - Duration LA
Rarely indicated for administration to children
(long duration soft tissue anesthesia = increased risk of
self-inflicted soft tissue injury)
•
Duration of pulpal anesthesia = >90 minutes (nerve block)
•
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Endodontics
Post-surgical pain control
•
Pre-surgical NSAID po 1 hr. prior to appointment
Indicated for:
LA of choice for surgery
•
Dental therapy of > 2 hour duration
•
Articaine, Lidocaine, Mepivacaine
Long-acting LA at end of surgery just prior to discharge of patient
Bupivacaine
NSAID on timed basis (q4,6,8h) for xx days
Post-surgical telephone call early evening
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Articaine
4% with
epinephrine
Articaine
1:100,000
1:200,000
•
•
Synthesized in Germany 1969
Introduced Germany 1976
1st & only Local anesthetic designed for dentistry
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Articaine 4% Epinephrine 1:100,000 & 200,000
0
1:100,00
•
1:200,000
•
Duration of pulpal anesthesia (infiltration) = 60 minutes
•
Duration of pulpal anesthesia (nerve block) = 60 minutes
•
Duration of soft tissue anesthesia = 3 - 5 hours
Indicated for:
•
Dental therapy of approximately 60 minute duration
•
•
quadrants
1:100,000
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1:200,000
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•
Pregnancy
Indicated for:
1:100,000
•
Pregnant patients*
•
Nursing mothers*
•
Mandibular infiltration in adult
patients*
&
Nursing
00
1:200,0
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Pregnancy
USA FDA
Basic rules:
1st trimester . . . NO ELECTIVE DENTAL CARE
Greater risk of spontaneous abortion & fetal malformation
Pregnancy classification
Definition
A
[Generally considered safe] Controlled studies show no risk in 1st trimester; no
evidence of 2nd or 3rd trimester risk; risk of fetal harm remote
B
[Caution advised] Animal studies show no risk or adverse fetal effects but controlled
human 1st trimester studies not available/do not confirm; no evidence of 2nd or 3rd
trimester risk; fetal harm possible but unlikely; see package insert for drugspecific recommendations
C
[Weigh risk/benefit] Animal studies show adverse fetal effect(s) but no controlled
human studies OR no animal or human studies; weigh possible fetal risk vs.
maternal benefit; see package insert for drug-specific recommendations
C/D/D
[Weigh risk/benefit] Category C in 1st trimester but positive evidence of human fetal
risk in 2nd and 3rd trimester; maternal benefit may outweigh fetal risk in serious
or life-threatening situations; see package insert for drug-specific
recommendations
2nd trimester & early 3rd trimester . . . DENTAL CARE, if necessary
late 3rd trimester . . . DENTAL CARE only if absolutely necessary
D
X
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[Weigh risk/benefit] Positive evidence of human fetal risk; maternal benefit may
outweigh fetal risk in serious or life-threatening situations; see package insert for
drug-specific recommendations
[Contraindicated] Positive evidence of serious fetal abnormalities in animals,
humans, or both; fetal risks clearly outweigh maternal benefit© 2015 Dr. Stanley F. Malamed
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Nursing
Drug
Lactation category
Definition
S
Safe for nursing infant; medication usually compatible
with breast-feeding
S?
Safety in nursing infants unknown; inadequate
literature available
S*
Potential for significant effects on nursing infants;
medication should be given with caution
NS
Not safe for nursing infants; medication
contraindicated or requires cessation of breast-feeding
Pregnancy classification
Nursing
When using articaine, nursing mothers may
choose to pump and discard breast milk for
approximately 4 hours (based on plasma half
life) following an injection of articaine (to
minimize infant ingestion) and then resume
breastfeeding.
Articaine
C
Bupivacaine
C
Lidocaine
B
Mepivacaine
C
S?
S
S?
Prilocaine
B
Safety unknown – exercise caution
Epinephrine
C
*NS
LA concentrations - OK
*Large doses,
such as in ACLS
USA FDA
USA FDA
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•
Should I use articaine 4% with
1:100,000 or 1:200,000 epineprine for
PAIN CONTROL?
•
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
•
PAIN CONTROL
1:100,000
•
00
1:200,0
CONTROL.
Therefore, logically, the
1:200,000 epinephrine
concentration would be
preferred for PAIN
CONTROL
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1:200,000
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•
Should I use articaine 4% with
1:100,000 or 1:200,000 epineprine
for HEMOSTASIS?
0
1:100,00
•
•
•
•
For HEMOSTASIS during
surgical procedures, small
volumes of 1:100,000
epinephrine infiltrated is
recommended.
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End session #1
Short-duration (~30 minutes)
Mepivacaine 3%
•
(all with vasoconstrictor)
•
Long-duration (>90 minutes)
•
Bupivacaine 0.5% (with vasoconstrictor)
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INJECTION
TECHNIQUES
and the
DENTAL SPECIALTIES
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LOCAL ANESTHETICS are the
SAFEST and MOST EFFECTIVE
drugs in medicine for the
PREVENTION & MANAGEMENT of pain
INJECTION
TECHNIQUES
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LOCAL ANESTHETICS
are the only drugs that actually
PREVENT PAIN
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Depositing LA anywhere along the IA nerve will produce pain control
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Deposit a Local Anesthetic
Close to a Nerve
and It WILL
Produce Pain Control
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N = 121
So, when problems achieving
clinically adequate pain control
occur . . .
Where do they happen?
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
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N = 121
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,
Canine, and
Incisors,
31%
Mandibular Premolars
8
29
18
41
25
can be easily accomplished
55%
Mandibular Molars
20
47
32
21
1
16%
Anesthesia of
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Incisive NB
Incisive NB
aka Mental NB
aka Mental NB
(incorrectly)
Needle: 27 gauge short
Insertion: MB fold at or anterior
to mental foramen
Target: Mental nerve as it exits
mental foramen
Volume: 0.6 mL
Aspiration: 5.7%
Insert needle in buccal fold and
advance towards mental
foramen
Aspirate
Deposit 0.6 mL outside
foramen
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(incorrectly)
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Incisive NB
aka Mental NB
(incorrectly)
Apply finger pressure for
2 minutes
Video
Vas = 0 -2
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The limited success rate for the IANB has led to the
development of alternative techniques:
Gow-Gates Mandibular Nerve Block
Vazirani - Akinosi (closed mouth) Mandibular Nerve Block
Periodontal ligament injection (intraligamentary)
Intraosseous anesthesia
So, now we’re left with
those ‘darned’
mandibular molars!
Articaine HCl via buccal infiltration
Buffered local anesthetics
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Mandibular anesthesia
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 The traditional ‘Mandibular Block’ has the LOWEST success rate
of all major nerve blocks in the human body
JADA 2000;131:901-907
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Bone is TOO thick
Lack of consistent anatomy
THE problem with mandibular anesthesia, in the adult,
is the density of the cortical plate of bone.
It precludes the successful administration of supraperiosteal anesthesia
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A second problem with mandibular anesthesia, in the adult,
is the lack of consistent landmarks
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Inferior Alveolar NB N = 121
Tooth
group
Often
Sometimes
Rarely
Very Rarely
Never
Mandibular
Incisors
4
6
17
39
55
Mandibular
Canines
4
10
23
39
45
“Mandibular NB”
Inferior Dental Block
The ‘HALSTED Approach’
55%
Mandibular
Premolars
8
29
18
41
25
Mandibular
Molars
20
47
32
21
1
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Inferior Alveolar NB “Mandibular NB”
Needle: 25- or 27- gauge long
Insertion: soft tissue on medial
border of mandibular ramus
Target: IA nerve on lingual aspect
Immediately following completion of IANB . . .
of ramus prior to entering
mandibular foramen
Volume: 1.5 mL
Aspiration: 10% - 15%
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Buccal NB “Long” Buccal
Needle: 25- or 27- gauge long
Insertion: mucus membrane distal
and buccal to last mandibular molar
Target: buccal nerve passing over
border of ramus
Volume: 0.3 mL
Aspiration: 0.7%
VAS = 3 -8
Video
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Following completion of
IANB & Buccal NBs . . .
Seat patient comfortably upright
Speeds onset of anesthesia
Video
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Inferior Alveolar NB “Mandibular NB”
The most common reason for missing the IANB is
depositing LA solution too low.
(BELOW the mandibular foramen)
Inferior Alveolar Nerve Block
A little higher is
a little better
The ‘nerve’ is gone!
The traditional IANB deposits LA at the LOWEST part if the IAN
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Inferior Alveolar NB Inferior Alveolar NB “Mandibular NB”
“Mandibular NB”
Disadvantages
1.
2.
3.
4.
Advantages
1. More extensive profound pulpal anesthesia
• Multiple preparations
Slower onset of pulpal anesthesia
Limited success
Not indicated for limited treatment
Prolonged duration of soft tissue anesthesia
• Lip & tongue
• Self-inflicted soft tissue injury
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The limited success of the IANB has led to the
development of alternative techniques:
JADA
September 2011
Vazirani - Akinosi (closed mouth) Mandibular Nerve Block
Is the ‘Mandibular
Block’ Passé?
Periodontal ligament injection (intraligamentary)
Intraosseous anesthesia
Articaine HCl via buccal infiltration
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102
JADA
September 2011
So the question is:
Is the
INFERIOR ALVEOLAR
NERVE BLOCK
Passé ?
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2013
Rights
Dr. Stanley
Reserved
F. Malamed
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JADA
September 2011
1973 . . .
©All
2013
Rights
Dr. Stanley
Reserved
F. Malamed
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George Albert Edward Gow-Gates Gow-Gates Mandibular Nerve Block
1910 - 2001
If a little higher is a little better,
a lot higher is a lot better
The Gow-Gates technique deposits LA at the HIGHEST area
George Gow-Gates
@ Westmeade Dental Hospital, 1993
The Gow-Gates technique is the only true MANDIBULAR NB
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Advantages
2003
1. Higher success rate . . . once you learn it
2. Lower aspiration rate
3. Complete anesthesia of quadrant
Video
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Vazirani SJ. Closed mouth mandibular nerve block:
a new technique.
Dr. Sunder VAZIRANI
Dent Dig 66:10-3, 1960.
Disadvantages
Dr. Oyekunle J. AKINOSI
1. Learning curve . . . “once you learn it”
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Vazirani-Akinosi Nerve Block
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Akinosi-Vazirani Mandibular NB
Vazirani-Akinosi Mandibular NB
Advantages
1. “Successful” when trismus is present
Video
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Akinosi-Vazirani Mandibular NB
Vazirani-Akinosi Mandibular NB
Vazirani-Akinosi Nerve Block
Disadvantages
Inferior Alveolar Nerve Block
1. No bone contact so have to
‘guesstimate’ depth of penetration
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JADA
September 2011
1980’s
Periodontal Ligament Injection,
Intraosseous &
Intraseptal (Crestal)
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Periodontal Ligament Injection (PDL)
27 gauge short needle
Place interproximally
SLOWLY deposit 0.2 mL per root
Video
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122
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
1980’s . . .
Intraosseous Anesthesia (IO)
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
Leonard M, J Amer Dent Assoc October 103(4): 571-575, 1981
91% successful
mandibular molars
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X-Tip
Stabident Video
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Use a gentle “pecking” motion
to penetrate the cortical plate.
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Intraosseous Anesthesia (IO)
DISADVANTAGES
Highly vascular region
ADVANTAGES
Relatively comfortable
X-Tip
LA OD
Single or multiple tooth
anesthesia
Vasopressor “shakes”
No lip / tongue
Can’t locate hole with needle
use 1:200k or plain
Video
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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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7.00
3.30
+/- 0.67
Duration 23.10
32.10
+/- 2.13
Pain
IANB
+/- 0.71
Onset
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Crestal
Winter 2011 5(1): 17-22, 2011
+/- 2.02
1.54
3.44
+/- 0.18
+/- 0.22
<0.001
<0.05
<0.001
mL 1.99 mL
Volume 0.4
+/- 2.07
Winter 2011 5(1): 17-22, 2011
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Winter 2011 5(1): 17-22, 2011
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Local Anesthesia
&
DENTAL SPECIALTIES
Pediatric Dentistry
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Pediatric Dentistry
Considerations
(1) Local anesthetic dosage
Seizure starts
(overdose, toxic reaction)
(2) Self-inflicted soft tissue injury
(residual soft tissue anesthesia)
Local anesthetic dosage
(3) Technique
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(overdose, toxic reaction)
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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
Self-inflicted soft tissue injury
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13% of pediatric patients receiving IANB suffer post-treatment traumatic injury to soft tissues.
Age
%
with soft tissue trauma
< 4 years
18%
4 - 7 years
16%
8 - 11 years
13%
12+
7%
Self-inflicted soft tissue injury
Tongue / lips most common
Children, handicapped adults
Advise parent / guardian
Select appropriate LA
Select appropriate technique
PDL, IO
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.
Local anesthesia reversal agent:
phentolamine mesylate
(Oraverse)
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Phentolamine mesylate
PM is a vasodilator
Increases blood flow into area of LA deposition
Technique
Speeds up discussion of LA out of injection site
Minimal increase in LA blood level
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Pediatric Dentistry
Pediatric Dentistry
Needle
Maxillary
Short needle appropriate until anatomy dictates long needle
Volume
All 1º teeth anesthetized by infiltration
1st permanent molar may be difficult
ASA NB for all 1º teeth
Lesser volumes of LA required
Technique
Technique
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Pediatric Dentistry
Periodontology
Mandibular
Infiltration OK for 1º mandibular teeth
Incisive nb for ALL 1º teeth in mandible
0.45 mL
Try to avoid long-duration LA’s
Technique
IANB not required
Foramen lower in child
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Periodontology
Periodontology
Considerations
Hemostasis
To achieve hemostasis the vasopressor must be injected into the
surgical site
Infiltration, not nerve block for hemostasis
(1) Hemostasis
(2) Post-surgical pain control
1:50k and 1:100k provide clinically adequate hemostasis
1:200k does NOT provide clinically adequate hemostasis
All Rights Reserved
147
All Rights Reserved
148
Periodontology
Endodontics
Bupivacaine
All Rights Reserved
All Rights Reserved
149
150
Endodontics
Endodontics
Considerations
Fear of dentistry
Effects of inflammation on LA
(1) Fear of dentistry
(2) The dilemma of the “Hot” mandibular molar
All Rights Reserved
151
r
ide
s
n
Co
s
on
ati
Effects of infection on LA
Long-term pain (chronic)
Co
ns
id
er
at
io
ns
Recently acute pain
Fear of dentistry
152
All Rights Reserved
The scared dental patient
OVERREACTS
to incoming sensory stimulation, be it visual, auditory,
proprioceptive, or nociceptive © 2015 Dr. Stanley F. Malamed
All Rights Reserved
All Rights Reserved
153
154
Routes of Drug Administration
The goal of sedation is
DISTRACTION
Oral sedation
Inhalation sedation
N2O – O2
To take the patients mind off
of what is happening to them
whilst in the dental chair
Intravenous sedation
Intranasal sedation
All Rights Reserved
155
All Rights Reserved
156
The Herman Ostrow
School of Dentistry of U.S.C.
The overall percentage of medical emergencies
occurring within the postdoctoral ENDODONTICS
clinic is significantly higher than expected.
Most result from either the patients FEAR of
dentistry and/or to the INABILITY TO OBTAIN
PROFOUND ANESTHESIA when extirpating the
pulpal tissues.
All Rights Reserved
Deal with the
FEAR first
then PAIN will be
a minor problem
Milgrom P, Weinstein P, Kleinknecht R, Getz T
Treating fearful dental patients, Reston 1980
All Rights Reserved
157
158
Endodontics
The Dilemma of the
Infected mandibular molars
‘Hot’ Mandibular Molar
Effects of inflammation on LA
Effects of infection on LA
Long-term pain (chronic)
Recently acute pain
All Rights Reserved
159
Stanley F. Malamed, D.D.S.
Dentist Anesthesiologist
Emeritus Professor of Anesthesia & Medicine
Ostrow School of Dentistry of U.S.C.
© 2014
All Rights Reserved
160
Endodontic “Tricks”
N = 121
Dental
pathology
Almost always
Average Caries
-
-
17
46
58
Deep
Caries
-
2
34
56
29
Chronic
Pulpitis
1
4
44
42
30
84%
Exacerbated
Chronic Pulpitis
2
22
60
30
7
89%
Acute Pulpitis
2
26
61
26
6
Often
Sometimes
Rarely
Never
Assume all is ‘good’
1. Inferior alveolar nerve block
a. Preferably buffered local anesthetic (lidocaine or articaine) + epinephrine
2. Supplement IANB with articaine infiltration in buccal fold of tooth to be treated
Consider SEDATION - N2O-02 preferred
If necessary:
3. Intraosseous
a. Distal to tooth being treated
4.Final choice: Intrapulpal injection
All Rights Reserved
All Rights Reserved
161
162
Endodontics
Bupivacaine
Local Anesthesia Considerations in Endodontic Treatment
Bahcall, J. May 2012
163
All Rights Reserved
164
Oral & Maxillofacial Surgery
Considerations
(1) Pain control
All Rights Reserved
All Rights Reserved
165
166
Pain control
Techniques
Drugs
Articaine
Lidocaine
Mepivacaine
Bupivacaine
Maxillary
Mandibular
Infiltration
PSA
MSA
ASA
AMSA
V2 NB
IANB
Gow-Gates
Vazirani-Akinosi
Incisive
Bupivacaine
All Rights Reserved
167
All Rights Reserved
168
Is the ‘Mandibular’ Block Passé?
So . . .
Is the
INFERIOR ALVEOLAR
NERVE BLOCK
Passé ?
169
Maybe
NOT YET,
but . . .
you’ve got
great options
170
Is the ‘Mandibular’ Block Passé?
Options:
Incisive (mental) nerve block
Gow-Gates mandibular nerve block
Akinosi-Vazirani nerve block
PDL, Intraosseous, Intraseptal
Articaine by mandibular infiltration
Buffered lidocaine
171
End session #2
172
FUTURE TRENDS
in
PAIN CONTROL
All Rights Reserved
173
All Rights Reserved
174
In my more than 40-year career
teaching pain control in dentistry I
have been involved with many, many
“new” ideas and concepts seeking to
improve pain control for dentists and
their patients
Periodontal Ligament Injection
Intraosseous (IO)
Electronic Dental Anesthesia (EDA)
Computer Controlled Local
Anesthetic Delivery (C-CLAD)
Articaine
Local Anesthesia Reversal Agent
Buffered Local Anesthetics
Nasal Local Anesthetic Mist
Periodontal Ligament Injection
Intraosseous (IO)
Iontophoresis
Electronic Dental Anesthesia (EDA)
Computer Controlled Local Anesthetic Delivery
(C-CLAD)
Articaine HCl
Local Anesthesia Reversal Agent (OraVerse® Phentolamine)
Buffered Local Anesthetics (Onset®)
Nasal Local Anesthetic Mist (Kovanest®)
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175
All Rights Reserved
176
JADA
September 2011
Articaine - Mandibular infiltration
The LA ‘ON’ switch
The LA ‘OFF’ switch
Maxillary anesthesia without injection
C-CLAD - (Dr. Mark Hochman)
All Rights Reserved
177
178
Articaine
ARTICAINE
0
1:100,00
1:200,000
All Rights Reserved
179
Ultracain
Septocaine
Artinibsa
Articadent
Vivacaine
Septanest
Alphacaine
Zorcaine
All Rights Reserved
180
Articaine
4% with
epinephrine
0
1:200,000
1:100,00
1:100,000
1:200,000
•
•
Synthesized in Germany 1969
Introduced Germany 1976
1st & only Local anesthetic designed for dentistry
•
Duration of pulpal anesthesia (infiltration) = 60 minutes
•
Duration of pulpal anesthesia (nerve block) = 60 minutes
•
Duration of soft tissue anesthesia = 3 - 5 hours
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181
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182
Buccal infiltration ARTICAINE
Articaine HCl
by Mandibular Infiltration
in Adults
Mandibular infiltration
John Meechan (UK)
Al Reader (USA)
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183
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184
Pain Control Options
1. As sole injection by mandibular infiltration
2. As a supplement to lidocaine IANB
Articaine as sole injection
by mandibular
buccal infiltration
All Rights Reserved
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185
186
Robertson D, Nusstein J, Reader A, Beck M, McCartney M.
The anesthetic efficacy of articaine in buccal infiltration
of mandibular posterior teeth.
J Am Dent Assoc 138:1104-1112, 2007
2007
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187
Design:
N = 60
Infiltration mandibular buccal fold by #30
• Lidocaine 2% + epi 1:100K
• Articaine 4% + epi 1:100K
Randomized
• At least 7 days apart
• 60 on right side
• 60 on left side
1.8 mL in 60 seconds
2007
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188
JADA 138(8):1104-1112, 2007
EPT
1st
2nd
1st
2nd
Teeth tested:
and
molar,
and
premolar
Baseline
• EPT @ 1 min = molars
• EPT @ 2 min = premolars
• EPT @ 3 min = Control (contralateral canine)
• Repeated cycle every 3 minutes for 60 minutes
Criteria for success:
• No response to 2 or more consecutive 80uA tests
•
•
2007
All Rights Reserved
Pulp test every
3 min
SUCCESS =
80/80 on 2
consecutive
tests
2007
Mandibular
2nd Molar
Mandibular
1st Molar
Mandibular
2nd Premolar
Mandibular
1st Premolar
189
Articaine
Lidocaine
75%
87%
92%
86%
45%
57%
p value for all:
>.0001
67%
61%
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190
Results -2:
Discussion -1:
The onset of successful anesthesia was significantly faster
for articaine than lidocaine for all 4 teeth tested
2007
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191
2007
All Rights Reserved
192
Discussion -2:
Thiophene ring:
JADA 138(8):1104-1112, 2007
> lipid solubility
Lidocaine
Benzene ring
Articaine
All Rights Reserved
2007
193
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194
Comment
1. The research required articaine infiltration
by tooth #30 (46)
2. In clinical situations you would logically
infiltrate the articaine in the buccal fold
adjacent to the tooth to be treated.
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195
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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196
Pulpal anaesthesia for mandibular central incisor teeth: a comparison of
infiltration and intraligamentary injections.
Int Endod J 35:629-634, 2002
Int Endod J 35:629-634, 2002
Design:
Articaine 4% + epi 1:100K
Lidocaine 2% + epi 1:80K
Infiltration buccal fold by lateral incisor
• 0.5 mL
Infiltration buccal & lingual by lateral incisor
• 0.5 mL per site
EPT q 3 min for 45 minutes
2002
Results-1:
Infiltration buccal fold by lateral incisor
• 94% articaine; 70% lidocaine
• Infiltration buccal & lingual by lateral incisor
• 97% articaine; 88% lidocaine
All Rights Reserved
2002
Int Endod J 35:629-634, 2002
197
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198
Mandibular Incisors
Int Endod J 35:629-634, 2002
Articaine B&L
Discussion:
Articaine B
Lidocaine B&L
Lidocaine B
All
Rights
© 2015 Dr. Stanley
Malamed
©F.
2013
Dr.Reserved
Stanley F. Malamed
All Rights Reserved
All Rights Reserved
199
2002
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200
Buccal
Buccal infiltration
infiltration -ARTICAINE
ARTICAINE
Advantages
1. Profound pulpal anesthesia
2. 30 to 40 minute duration of pulpal anesthesia
3. Minimal accessory soft tissue anesthesia
• Tongue
Disadvantage
I can’t think of any,
unless it doesn’t work!
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201
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202
Pain Control Options
Articaine infiltration
as a supplement
to IANB
All Rights Reserved
203
Kanaa JM, Whitworth JM, Corbett IP, Meechan JG
Articaine buccal infiltration enhances the effectiveness of
lidocaine inferior alveolar nerve block.
Int Endodont J 42:238-246, 2009
204
All Rights Reserved
Kanaa JM, Whitworth JM, Corbett IP, Meechan JG
Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block.
Int Endodont J 42:238-246, 2009
as a supplement to IANB
1st Molar
91.7%
IANB’s at each of 2 visits = 2% lidocaine + epi 1:80K
One visit = 4% articaine + epi 1:100K infiltration buccal fold 1st
molar (2.0 mL)
55.6%
One visit = ‘dummy injection’ buccal fold 1st molar
Pulp test for 45 minutes
All Rights
Reserved
All Rights
Reserved
All Rights Reserved
205
206
1st Premolar
Lateral Incisor
88.9%
77.8%
66.7%
19.4%
All Rights Reserved
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207
208
The local anesthetic
“ON SWITCH”
Buffered Local Anesthetics
Alkalinized Local Anesthetics
All
Rights Reserved
All Rights Reserved
All Rights Reserved
209
210
Intermediate - duration LAs - USA
Drug
How long does it take for pulpal
anesthesia to develop?
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211
Lidocaine
2%
Onset (textbook)
Pulpal
Soft Tissue
Epi
1:50k, 1:100k
3 - 5 min
60 min
3 - 5 hours
Mepivacaine Levonordefrin
1:20k
2%
3 - 5 min
60 min
3 - 5 hours
Prilocaine
4%
Epi
1:200k
3 - 5 min
60 min
3 - 8 hours
Articaine 4%
Epi
1:100k
1:200k
2 - 3 min
60 min
3 - 5 hours
Epi = Epinephrine (Adrenalin)
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212
1980
Where do these numbers . . .
Onset of anesthesia,
Duration of pulpal anesthesia,
Duration of soft tissue anesthesia
1st
edition
. . . come from?
1946 - 1973
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213
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214
Six-Hour Time Course for Pulpal Analgesia (EPT)
IANB Second Premolar
So the question is:
The other 5% are anatomical misses
95% of
patients will
(eventually) get
numb
if given a
45-minute
waiting period
Why?does it REALLY take for
How long
pulpal anesthesia to develop?
45 minutes
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215
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216
30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs
Data from 28 PRP Studies - 1078 Subjects (1991 - 2008)
IANB - Lido
28 peerreviewed
trials
100%#
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
90%#
#Chaney#(1991)(m)(L)#
#Hinckley#(1991)(m)(L)#
#McLean#(1993)(m)(L)#
80%#
N = 1078
#Childers#(1996)(m)(L)#
#Dagher#(1997)(m)(L)#
#Goldberg#(2008)(m)(L)#
70%#
#Goodman#(2006)(m)(L)#
Infiltration - Lido
#Hannan#(1999)(1m)(L)#
60%#
8 peer-reviewed
trials
#Hannan#(1999)(2m)(L)#
#Steinkruger#(2006)(m)(L)#
#Willet#(2008)(m)(L)#
50%#
#Vreeland#(1989)(m)(L)#
N = 416
The
SPAGHETTI
graph
40%#
IANB - Articaine
5 peer-reviewed
trials
30%#
20%#
N = 222
10%#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(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)#
#Mikesell#(2005)(m)(L)#
#Mikesell#(2005)(1p)(L)#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
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218
30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)
Data from 28 PRP Studies - 1078 Subjects (1991 - 2008)
100%#
Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)
100%#
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
#Chaney#(1991)(m)(L)#
90%#
90%#
#McLean#(1993)(m)(L)#
80%#
80%#
#Dagher#(1997)(m)(L)#
70%#
70%#
Lidocaine#IANB#Mean#
70%
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
60%#
60%#
#Willet#(2008)(m)(L)#
50%#
50%#
‘MEAN’
40%#
30%#
50% above
50% below
20%#
10%#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(L)#
At 4 minutes:
70% soft tissue numb
25% pulpal anesthesia
40%#
#McLean#(1993)(p)(L)#
#Dagher#(1997)(p)(L)#
30%#
25%
20%#
#Hannan#(1999)(p)(L)#
#Willet#(2008)(p)(L)#
#Mikesell#(2005)(m)(L)#
10%#
Lai,#et#al,#so>#?ssue#v.#EPT#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
0%#
30#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
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219
20#
22#
24#
26#
28#
30#
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220
100%#
100%#
90%#
90%#
85%
85%
80%#
80%#
70%#
70%#
60%#
60%#
50%#
50%#
40%#
At 6 minutes:
85% soft tissue numb
40%
30%#
20%#
10%#
OW!
70%
40%
40%#
30%#
25%
20%#
10%#
0%#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
0#
30#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
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221
222
Soft tissue anesthesia
is NEVER
a guaranteed sign of
pulpal anesthesia
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223
All Rights Reserved
Is there a guarantee?
The best* we have is using an
electric pulp tester
or
Freezing spray (e.g. Endo-Ice)
*Assumes no pulpal involvement
224
All Rights Reserved
Average for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean
Average for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean
100%#
100%#
Most doctors
wait ~10 minutes
90%#
80%#
80%#
70%#
70%#
N = 1078
Some
doctors
Many
practitioners
wait
15
minutes
(67%)
wait ~15 minutes
90%#
N = 1078
60%#
50%#
60%#
50%#
40%#
40%#
20%#
10%#
At 15 minutes:
30%#
At 10 minutes:
30%#
20%#
10%#
0%#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
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225
226
100%#
IANB: Lidocaine + epinephrine
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
90%#
#Chaney#(1991)(m)(L)#
80%#
#McLean#(1993)(m)(L)#
#Dagher#(1997)(m)(L)#
70%#
60%#
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
50%#
#Willet#(2008)(m)(L)#
40%#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(L)#
30%#
% clinically effective pulpal anesthesia
#McLean#(1993)(p)(L)#
20%#
#Dagher#(1997)(p)(L)#
10%#
#Hannan#(1999)(p)(L)#
#Willet#(2008)(p)(L)#
0%#
%
•
25 at 4 minutes
•
40% at 6 minutes
0#
60 at 10 minutes
•
67% at 15 minutes
•
95% at 45 minutes
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
26#
28#
30#
with Articaine?
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227
24#
Can we speed the onset of
anesthesia . . .
%
•
2#
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228
30-Minute Time Course, Pulpal Analgesia, IANB,
Why do doctors LIKE articaine?
Lidocaine,
Articaine
100%#
90%#
80%#
Ar/caine#IANB#Mean#
Anecdotal comments from dentists:
70%#
N = 222
“It works better”
Articaine
“I don’t miss as often”
Lidocaine
“Hard to get ‘numb’ patients are
easier to numb with articaine”
N = 1078
60%#
50%#
40%#
ARTICAINE
+ epinephrine
30%#
20%#
10%#
“It works faster”
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
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229
230
Can we speed the onset
of anesthesia
100%#
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
90%#
#Chaney#(1991)(m)(L)#
80%#
#McLean#(1993)(m)(L)#
#Dagher#(1997)(m)(L)#
70%#
60%#
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
50%#
#Willet#(2008)(m)(L)#
40%#
#Kanaa#(2006)(p)(L)#
#Chaney#(1991)(p)(L)#
30%#
#McLean#(1993)(p)(L)#
20%#
with Articaine?
NO
231
#Dagher#(1997)(p)(L)#
10%#
#Hannan#(1999)(p)(L)#
#Willet#(2008)(p)(L)#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
anesthesia . . .
by buffering the LA solution?
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232
100%#
30-Minute Time Course, Pulpal Analgesia, IANB,
Buffered Lidocaine
#Kanaa#(2006)(m)(L)#
#Nist#(1992)(m)(L)#
90%#
Lidocaine,
Articaine
#Chaney#(1991)(m)(L)#
100%#
80%#
#McLean#(1993)(m)(L)#
#Dagher#(1997)(m)(L)#
70%#
60%#
90%#
#Hannan#(1999)(1m)(L)#
#Hannan#(1999)(2m)(L)#
50%#
#Willet#(2008)(m)(L)#
Ar/caine#IANB#Mean#
40%#
#Kanaa#(2006)(p)(L)#
80%#
#Chaney#(1991)(p)(L)#
30%#
#McLean#(1993)(p)(L)#
20%#
#Dagher#(1997)(p)(L)#
10%#
#Hannan#(1999)(p)(L)#
67%
#Willet#(2008)(p)(L)#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
N = 18
30#
anesthesia . . .
70%#
60%#
50%#
40%#
30%#
by changing the pH of
the LA solution?
BUFFERED
lidocaine + epinephrine
20%#
10%#
#Buffered#Lido#IANB#
0%#
0#
2#
4#
6#
8#
10#
12#
14#
16#
18#
20#
22#
24#
26#
28#
30#
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233
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234
Can we speed the onset
of anesthesia
“ON SWITCH”
by buffering the solution?
YES
235
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236
Lidocaine
Local
anesthetics
are
INSOLUBLE
in water.
Mepivacaine
Articaine
Prilocaine
Bupivacaine
Hydrochloric acid
is added
to make the
drug water-soluble
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237
238
Mepivacaine HCl
Let’s look at an anesthetic cartridge
Lidocaine HCl
We inject the
acid-salt of the
local anesthetic
Bupivacaine HCl
pH
Articaine HCl
Prilocaine HCl
‘Plain’ LA solution (mepivacaine 3%) = ~6.5
Vasoconstrictor LA solution = ~3.5
Lemon juice = 3.3
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240
Lidocaine = RN
+
Hydrochloric acid = H
The more acidic the solution
the greater the number of H
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241
242
H+
RN
+
So . . . inside the LA cartridge we have
Some H attach to RN forming RNH
+
three things: RN
+
H and RNH
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243
+
+
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244
RN is LIPID SOLUBLE and CAN cross the lipid-rich nerve membrane
% Un-ionized (RN) LA
pH
Lidocaine
Articaine Mepivacaine Bupivacaine
pKa 7.9
pKa 7.8
pKa 7.6
pKa 8.1
0.004
0.005
0.008
0.003
RN
3.5
RN
RN
(with epi)
RNH+ CANNOT cross the nerve membrane
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pH 3.5
The body will
SLOWLY
buffer the
anesthetic
solution to a
pH of 7.4
pH
Lidocaine
7.4
24.03%
75.97%
0.004%
99.996%
RN
RNH+
pKa 7.9
(body pH)
3.5
(with epi)
45 minutes ?
45 minutes ?
3.4
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pH 7.4
45 minutes ?
3.6
3.8
4
4.2
4.4
4.6
4.8
5
5.2
5.4
5.6
5.8
5.9
6
6.2
6.4
6.6
6.8
7
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
pH
The human body is a magnificent buffering machine
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The Medical Profession
& Local Anesthesia
% Un-ionized (RN) LA
6000x increase
in RN
pH
7.4
Lidocaine
pKa 7.9
Articaine Mepivacaine Bupivacaine
pKa 7.8
pKa 7.6
pKa 8.1
24.03
28.47
38.69
16.63
3.83
4.77
7.36
2.45
0.004
0.005
0.008
0.003
Dermatology
Plastics & Reconstructive Surgery
Allergists
(body pH)
6.5
(plain)
3.5
(with epi)
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Allows CO2 to Escape
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Medical use of Local Anesthetic Buffering
BUFFERING
with
Sodium Bicarbonate
Adsorbs active anesthetic
Draws CO2 out of solution
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So, what has happened to make LA
buffering a reality in dentistry?
pH = 7.35
Stabilization
BUFFERING
of the
Sodium Bicarbonate
with
NaBicarbonate Solution
pH = 7.35
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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
•
•
Summary
•
•
Clinical Trial Data
•
•
•
•
Patients were appointed twice.
Received IANB each time
• At least 1 week between appointments
Pulp tested mandibular premolar prior to start
IANB administered
• Traditional lidocaine + epi 1:100k (pH ~3.5)
• Buffered lidocaine + epi 1:100k (pH 7.35)
Timer started
Endo-ice applied to premolar q20sec until no response
Confirmed with EPT
Onset of anesthesia when BOTH tests negative
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Injection Pain Reported by Participants
10
Standard Anesthetic
10
9
9
8
8
7
7
Buffered Anesthetic
6
6:37
Pain
10*cm*
VAS
5
Average:
2.3
1:51
6
5
4
4
3
3
2
2
1
1
0
Average:
0.6
0
*******************6**************5****************4**************3****************2*************1*************
*
258
(100mm VAS)
********************1****************2*****************3****************4******************5*******************6******
*
No. of Participants at each 5mm pain interval
No. of Participants at each 5mm pain interval
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Clinical Data – Pain Free Injections
Clinical Data – Patient Preference
50%
80%
44%
72%
38%
44% of buffered anesthetic patients
experienced zero injection pain
72 % of patients
rated buffered
anesthetic as the
more
comfortable
injection
25%
6% of traditional anesthetic patients
13%
experienced zero injection pain
6%
60%
40%
20%
17%
11%
0%
0%
No*Difference
Control
Buffered
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Control
Buffered
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Clinical Data – Onset less than 2 minutes
80%$
71%$
70%$
60%$
50%$
40%$
30%$
20%$
12%$
10%$
0%$
Lidocaine$w/$Epi$
Buffered$Lidocaine$w/$Epi$
alkalinized 2% lidocaineWhat%Percentage%of%Par.cipants%Achived%Pulpal%
with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11, 2013
Anesthesia%in%Under%2%Minutes?%
Video
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© 2013Dr.
Dr. Stanley
F. Malamed
© 2015
Stanley
F. Malamed
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262
Buffering Lidocaine HCl
Dr. Dawn
Green
Lidocaine 2% + epinephrine 1:100,000 = pH 3.5
BUFFERED
Las Vegas, NV
Lidocaine 1.75% + epi 1:125,000 + CO2 + NaHCO3 = pH 7.4
Video
More dilute
6,000x more active ions to enter nerve
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Buffered Local Anesthetics
When buffering is done properly the following advantages
can be expected from the increase in pH:
(1) More comfortable injection for patient
pH of anesthetic 7.35 to 7.5
(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)
The
Mandibular anesthesia - IANB
1. Administer buffered lidocaine IANB
2. DO NOT LEAVE THE PATIENT !!!
3. You know if your block is successful in 2 minutes
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The
Onset® approach
266
Onset® approach
The
Mandibular anesthesia - IANB
Onset® approach
Maxillary anesthesia
4. Check for pulpal anesthesia:
• EPT or Endo-Ice
5. In 2 minutes following IANB
either begin tooth preparation or
readminister LA
Follow same procedure for maxillary teeth.
Onset time is at least as rapid
- if not faster following infiltration
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“ON SWITCH”
“OFF SWITCH”
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Intranasal Drug Administration
Intranasal Local Anesthesia
in the Maxilla
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Intranasal Drug Administration
Emergency medicine
Pediatric grand mal status . . . Midazolam
Pediatric sedation (dentistry) . . . Midazolam
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Notice EMT place syringe in nose
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274
Intranasal Local Anesthetic Mist
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By late-2015, early 2016 (hopefully)
in the USA
we will be able to administer
a local anesthetic intranasally
to provide profound pulpal anesthesia
from #4 to #13
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(#1.1 to 1.5 and 2.1 to 2.5)
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Kovanest
3% Tetracaine
Oxymetazoline
Ester-type local anesthetic
Commonly used by ENT surgeons
Vasoconstrictor
Has ‘track record’ as safe & effective IN
Active ingredient in ‘Afrin’ & other nasal
decongestants
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2013 Dr. Stanley
F. Malamed
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F. Malamed
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278
Injectable
(lidocaine + epi)
Phase 2 clinical trial
94% success
1st molar to 1st molar
3% Tetracaine
Oxymetazoline
(active ingredient in Afrin nasal spray)
Sprayed into R & L nares
N = 48
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Nasal Mist
84% success
1st molar to 1st molar
100% success
Premolar to premolar
Palate
16% failure on 1st molar
JADA 143(8):872-880, 2012
© 2014
Stanley F. F.
Malamed
© 2015
Dr.Dr.Stanley
Malamed
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© All
2013
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F. Malamed
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Whats’s New
in
Local Anesthesia
Light-activated / Light-inactivated
Local Anesthetic
In the more distant future
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Stanley
F. Malamed
Stanley F. Malamed
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284
Optical control of painsensing neurons. QAQ
selectively enters pain
sensing neurons and
silences their activity (top,
green light). Illumination
with violet light (bottom)
quickly restores signal
conduction
Ultra
Long-Acting
Analgesia
Neosaxitoxin
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Neosaxitoxin
Over 1 week of analgesia (in rodents)
without histologic or functional sequelae
One of a group of natural
neurotoxic alkaloids,
commonly known as the
paralytic shellfish toxins (PSTs)
Saxitoxin
Tetrodotoxin
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Stanley
F. Malamed
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20?? DRUGS Neosaxitoxin
Saxitoxin
Long-acting local ANESTHETIC
Long-acting local ANALGESIC
The ‘RED TIDE’
• Chile & Harvard
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Stanley
F. Malamed
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F. Malamed
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Neosaxitoxin
Over 1 week of analgesia (in rodents)
without histologic or functional sequelae
© 2015© 2014
Dr. Dr.
Stanley
F. Malamed
Stanley F. Malamed
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292
malamed@usc.edu
Thank you for
listening . . .
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2015 Dr. Stanley F. Malamed

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2015 Dr. Stanley F. Malamed - Fourth District Dental Society

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