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School of Dentistry
University of Alabama at Birmingham
February 2016
John Nusstein, DDS, MS
Professor and Chair, Division of Endodontics
The Ohio State University, Columbus, Ohio
Diplomate, American Board of Endodontics
Introduction
We have published a number of our anesthesia articles in the Journal of Endodontics. There are a number of reasons for this. The JOE is one of the most respected journals in dentistry. Additionally, in the past, oral surgeons have been the resource for local anesthesia. By publishing our articles in the JOE, the current knowledge endodontists have made us the authorities for local anesthesia. This should come as no surprise since we deal with failures of pulpal anesthesia on a daily basis. We should take advantage of this benefit by working with our referrals regarding the common problems they have with pulpal anesthesia in asymptomatic patients. The following information may be helpful to you and your referring dentists.
IMPORTANT CLINICAL FACTORS RELATED TO LOCAL ANESTHESIA
Before reviewing the specifics of local anesthesia, we would like to provide an overview of some factors that are important to clinical anesthesia.
How do we traditionally confirm anesthesia clinically? Traditional methods to confirm anesthesia usually involve questioning the patient (Is your lip numb?"), soft tissue testing (e.g., lack of mucosal responsiveness to a sharp explorer), or simply commencing with treatment. The problem with these approaches is they may not be effective for determining pulpal anesthesia. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun18142491-4
Objective means of determining pulpal anesthesia in non-painful, vital teeth. A more objective measurement of anesthesia, in non-painful vital teeth, is obtained with an application of a cold refrigerant, or by using an electric pulp tester (EPT). Clinically, application of cold or the electric pulp tester can be used to test the tooth under treatment for pulpal anesthesia prior to beginning a clinical procedure. ADDIN EN.CITE Dreven19874510Dreven, L. J.Reader, A.Beck, M.Meyers, W. J.Weaver, J.1987An evaluation of an electric pulp tester as a measure of analgesia in human vital teethJ Endod135233-8May3473179Certosimo19964870Certosimo, A, Archer, R1996A clinical evaluation of the electric pulp tester as an indicator of local anesthesia.Oper Dent2125-30Loetscher19884880Loetscher, CAMelton, DCWalton, RA1988Injection regimen for anesthesia of the maxillary first molar.J Am Dent Assoc117337-40Jones200219010Jones, V. R.Rivera, E. M.Walton, R. E.2002Comparison of carbon dioxide versus refrigerant spray to determine pulpal responsivenessJ Endod287531-3AdultCold/du [Diagnostic Use]Comparative StudyCross-Over Studies*Dental Pulp Test/mt [Methods]Dry IceFemaleHumanHydrocarbons, Fluorinated/du [Diagnostic Use]MaleMiddle AgeSingle-Blind Method*Tooth, Nonvital/di [Diagnosis]Nusstein19982820Nusstein, J.Reader, A.Nist, R.Beck, M.Meyers, W. J.1998Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitisJ Endod247487-91Jul9693577Hsiao-Wu200740800Hsiao-Wu, GW, Susarla, SM, White, RR2007Use of the cold test as a measure of pulpal anesthesia during endodontic therapy: A randomized, blinded, placebo-controlled clinical trailJ Endod33406-105-10
Determining pulpal anesthesia in painful, vital teeth. Clinically, after administration of local anesthesia, the cold or electric pulp tester can be used to test painful, vital teeth for pulpal anesthesia prior to beginning the endodontic procedure. ADDIN EN.CITE Dreven19874510Dreven, L. J.Reader, A.Beck, M.Meyers, W. J.Weaver, J.1987An evaluation of an electric pulp tester as a measure of analgesia in human vital teethJ Endod135233-8May3473179Certosimo19964870Certosimo, A, Archer, R1996A clinical evaluation of the electric pulp tester as an indicator of local anesthesia.Oper Dent2125-30Loetscher19884880Loetscher, CAMelton, DCWalton, RA1988Injection regimen for anesthesia of the maxillary first molar.J Am Dent Assoc117337-40Jones200219010Jones, V. R.Rivera, E. M.Walton, R. E.2002Comparison of carbon dioxide versus refrigerant spray to determine pulpal responsivenessJ Endod287531-3AdultCold/du [Diagnostic Use]Comparative StudyCross-Over Studies*Dental Pulp Test/mt [Methods]Dry IceFemaleHumanHydrocarbons, Fluorinated/du [Diagnostic Use]MaleMiddle AgeSingle-Blind Method*Tooth, Nonvital/di [Diagnosis]Nusstein19982820Nusstein, J.Reader, A.Nist, R.Beck, M.Meyers, W. J.1998Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitisJ Endod247487-91Jul9693577Hsiao-Wu200740800Hsiao-Wu, GW, Susarla, SM, White, RR2007Use of the cold test as a measure of pulpal anesthesia during endodontic therapy: A randomized, blinded, placebo-controlled clinical trailJ Endod33406-10Reisman19972910Reisman, D.Reader, A.Nist, R.Beck, M.Weaver, J.1997Anesthetic efficacy of the supplemental intraosseous injection of 3% mepivacaine in irreversible pulpitisOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics846676-82Dec9431539Cohen199338910Cohen, HCha, BSpangberg, L1993Endodontic anesthesia in mandibular molars: A clinical study.J Endod19370-35-12 If the patient responds positively to the stimulus, then pulpal anesthesia has not been obtained and supplemental anesthesia should be administered. However, in painful, vital teeth (eg., irreversible pulpitis), the lack of response to pulp testing may not guarantee pulpal anesthesia even if there is vital tissue present in the pulp chamber. ADDIN EN.CITE Dreven19874510Dreven, L. J.Reader, A.Beck, M.Meyers, W. J.Weaver, J.1987An evaluation of an electric pulp tester as a measure of analgesia in human vital teethJ Endod135233-8May3473179Nusstein19982820Nusstein, J.Reader, A.Nist, R.Beck, M.Meyers, W. J.1998Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitisJ Endod247487-91Jul9693577Hsiao-Wu200740800Hsiao-Wu, GW, Susarla, SM, White, RR2007Use of the cold test as a measure of pulpal anesthesia during endodontic therapy: A randomized, blinded, placebo-controlled clinical trailJ Endod33406-105, 9, 10 Therefore, if a patient experiences pain when the endodontic procedure is started, after negative pulp testing, supplemental anesthesia is indicated.
Naturally, if the chamber is necrotic and the canals are vital, no objective test can predict the level of clinical anesthesia. However, as suggested by Hsiao-Wu, et al. ADDIN EN.CITE Hsiao-Wu200740800Hsiao-Wu, GW, Susarla, SM, White, RR2007Use of the cold test as a measure of pulpal anesthesia during endodontic therapy: A randomized, blinded, placebo-controlled clinical trailJ Endod33406-1010, cold testing adjacent teeth for anesthesia may provide evidence of anesthesia in the working area.
Previous Difficulty with Anesthesia. Patients who report a history of previous difficulty with anesthesia are more likely to experience unsuccessful anesthesia. ADDIN EN.CITE Kaufman198438920Kaufman, E.Weinstein, P.Milgrom, P1984Difficulties in achieving local anesthesiaJ Am Dent Assoc108205-813 These patients will generally identify themselves with comments such as "Novocaine doesnt work on me" or "A lot of shots are needed to get my teeth numb." A good clinical practice is to ask the patient if they have had previous difficulty achieving clinical anesthesia. If they have had these experiences, supplemental injections should be considered.
Red Haired Patients. Red hair is a phenotype for melanocortin-1 receptor gene, which is associated with red hair, fair skin, and freckles. There is evidence in medicine that these patients may be more resistant to anesthetic agents.13a,b However in dentistry, red hair was unrelated to success rates of the inferior alveolar nerve block.13c Red hair was associated with higher levels of dental anxiety.13c
MANDIBULAR ANESTHESIA Restorative Dentistry
Conventional Inferior Alveolar Nerve Block
As a frame of reference, we will review the expected outcomes following administration of a conventional inferior alveolar nerve block, to asymptomatic patients, using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine. While anesthesia requirements vary between dental procedures, the following discussion will concentrate on pulpal anesthesia.
Anesthetic Success
One way to define anesthetic success is the percentage of subjects who achieve two consecutive 80 readings (EPT) within 15 minutes and continuously sustain this lack of responsiveness for 60 minutes. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 In other words, the objective is to achieve anesthesia within 15 minutes and have anesthesia that lasts 1 hour. This objective is equally important to restorative dentistry as it is for endodontic treatment. What then is the percentage of anesthetic success? For the first molar it was 53%, for the first premolar it was 61%, and for the lateral incisor it was 35%. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 Therefore, success occurs most often in the molar and premolar teeth. It is important to realize that 100% of the subjects in these studies ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 had profound lip numbness.
Anesthetic Failure
Anesthetic failure has been defined as the percentage of subjects who never achieved two consecutive 80 EPT readings at any time during a 60-minute period. These patients have the highest potential for pain during a dental procedure. How often does failure occur? For the first molar it was 17%, for the first premolar it was 11%, and for the lateral incisor it was 32%. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 Again, 100% of these subjects had profound lip numbness.
Slow Onset
In most cases following the conventional inferior alveolar nerve block injection, the onset of pulpal anesthesia usually occurs within 15-16 minutes. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-7Agren198139070Agren, EDanielsson, K1981Conduction block analgesia in the mandible. A comparative investigation of the techniques of Fischer and Gow-Gates.Swed Dent J591-91-4, 20-25 However, in some patients onset will be delayed. Slow onset is defined as the percentage of subjects who achieved an 80 EPT reading after 15 minutes. Slow onset occurs about 19-27% of the time in mandibular teeth; about 8% of patients have onset after 30 minutes. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-7Agren198139070Agren, EDanielsson, K1981Conduction block analgesia in the mandible. A comparative investigation of the techniques of Fischer and Gow-Gates.Swed Dent J591-91-4, 20-25 In contrast to the onset of pulpal anesthesia, the onset of lip numbness occurs usually within 5-9 minutes. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun18142491-4
Duration
Duration of pulpal anesthesia in the mandible is very good. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 Therefore, if patients are anesthetized initially, anesthesia usually persists for approximately 2 1/2 hours with 2% lidocaine with 1:100,000 epinphrine. ADDIN EN.CITE Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon3149923
What Does Lip Numbness Mean?
The presence of soft tissue anesthesia (usually measured by lip numbness or lack of mucosal responsiveness to a sharp explorer) does not adequately indicate pulpal anesthesia. ADDIN EN.CITE Vreeland19894440Vreeland, D. L.Reader, A.Beck, M.Meyers, W.Weaver, J.1989An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve blockJ of Endod1516-12Jan2607268McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar8509754Chaney19914400Chaney, M. A.Kerby, R.Reader, A.Beck, F. M.Meyers, W. J.Weaver, J.1991An evaluation of lidocaine hydrocarbonate compared with lidocaine hydrochloride for inferior alveolar nerve blockAnesth Prog386212-6Nov-Dec1842158Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun1814249Hannan1999427010397653Hannan, L.Reader, A.Nist, R.Beck, M.Meyers, W. J.The use of ultrasound for guiding needle placement for inferior alveolar nerve blocksOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics1999Jun876658-65Wali198839040Wali, MReader, ABeck, MMeyers, W1988Anesthetic efficacy of lidocaine and epinephrine in human inferior alveolar nerve blocksJ Endodon14193 (abstract)Simon199039050Simon, F Reader, AMeyers, WBeck, MNist, R1990Evaluation of a peripheral nerve stimulator in human mandibular anesthesia.J Dent Res69278 (abstract)Fernandez C200540290Fernandez C,Reader A,Beck M,Nusstein J,2005A prospective, randomized, double-blind comparison of bupivacaine and lidocaine for inferior alveolar nerve blocksJ Endodon31499Nusstein2002413012640855Nusstein, J.Reader, A.Beck, F. M.Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocksGeneral Dentistry2002Jul-Aug504372-5; quiz 376-71-4, 20-24 This is in contradiction to the traditional view. However, the lack of soft tissue anesthesia is a useful indicator that the block injection was not administered accurately for that patient.
How often do missed blocks occur? A missed block is defined as not obtaining profound lip numbness within 15-20 minutes following an IAN block. Pulpal anesthesia will NOT be present with a missed block. We studied missed blocks in over 3,000 asymptomatic subjects and in emergency patients presenting with symptomatic irreversible pulpitis.25a What did we find? The incidence of missed blocks for asymptomatic subjects was 6% for the one-cartridge volume and 4% for the two-cartridge volume. For patients presenting with irreversible pulpitis, the incidence of missed blocks was 8% for the one-cartridge volume and 2% for the two-cartridge volume. In both asymptomatic subjects and patients with irreversible pulpitis, the two-cartridge volume was significantly better than the one-cartridge volume.
Alternate Anesthetic Solutions for the Inferior Alveolar Nerve Block
Plain Solutions: 3% Mepivacaine (Carbocaine, Polocaine, Scandonest) and 4% Prilocaine (Citanest Plain).
McLean and co-authors, ADDIN EN.CITE McLean19934370McLean, C.Reader, A.Beck, M.Meyers, W. J.1993An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100,000 epinephrine) for inferior alveolar nerve blockJ Endod193146-50Mar85097542 in an experimental study, have shown that 3% mepivacaine plain and 4% prilocaine plain are as effective as 2% lidocaine with 1:100,000 in an inferior alveolar nerve block. Cohen et al. ADDIN EN.CITE Cohen199338910Cohen, HCha, BSpangberg, L1993Endodontic anesthesia in mandibular molars: A clinical study.J Endod19370-312 in a clinical study of patients with irreversible pulpitis, also found that 3% mepivacaine and 2% lidocaine with 1:100,000 epinephrine were equivalent for inferior alveolar nerve blocks. Clinically, this is an important finding because when medical conditions or drug therapies suggest caution in administering epinephrine-containing solutions, 3% mepivacaine can be used as an alternative.
4% Prilocaine with 1:200,000 epinephrine (Citanest Forte) and 2% Mepivacaine with 1:20,000 Levonordefrin (Carbocaine with Neo-Cobefrin)
Hinkley and co-authors ADDIN EN.CITE Hinkley19914410Hinkley, S. A.Reader, A.Beck, M.Meyers, W. J.1991An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve blockAnesth Prog38384-9May-Jun18142494 in an experimental study, have shown that 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin are equivalent to 2% lidocaine with 1:100,000 in an inferior alveolar nerve block in achieving pulpal anesthesia.
L e v o n o r d e f r i n h a s 7 5 % a c t i v i t y a n d o n l y 2 5 % a c t i v i t y m a k i n g i t s e e m l y m o r e a t t r a c t i v e t h a n e p i n e p h r i n e ( 5 0 % a c t i v i t y a n d 5 0 % a c t i v i t y ) . A D D I N E N . C I T E <