Transcribed by Charles Buchanan Date of the Lecture: 10/17/14

[Diagnosis and Treatment of Oral Diseases] [Lecture 51/52] [Local Anesthesia] by

Dr. Malek
Im cutting out some fluff like like, umm, ok and you know because no one has
time for that.
[Slide 1] [Local Anesthesia]
[Dr. Malek] Good afternoon everyone. Lets start on time. Originally the length of this
lecture is supposed to be an hour and a half, I believe, but its going to be much shorter.
So Im condensing it to just the amount of information that you need. Lets start right
now so you can get out of here soon. Youre here till 5? Ok. Local anesthesia- Im pretty
much sure that youve received lectures from different disciplines regarding local
anesthesia or you will get in the future. But its a very important part of endo in
particular, and the reason is that if you have asked or heard people or mostly general
people scared of endo. And they dont like to get root canal treatments and its just kind
of a nightmare for people. And why do you think the reason is? They dont know what
youre doing and theyre not seeing what youre doing so its not the procedure theyre
afraid of. Its actually that pain that is associated with this procedure. So, this is maybe
the most important part of your treatment because if you do not really have a profound
anesthesia, even if you are the best endodontist and give the best RCT ever, they wouldnt
like to come back to you. And its going to be a failure for your career. But, the success
of RCT is really high, more than 90-95%. And the most of you, if youre doing the
simple root canal treatment, you will achieve that success. And if youre really making
the patient comfortable, they will like you and would come back. And they would think
that youre the best endodontist ever. I just want you to forget whatever youve been told
regarding local anesthesia for operative. For instance, youre doing a Class I on a molar,
even if its a maxillary molar - I know that some faculty may have suggested give them
the minimum amount of anesthesia, you dont need to give them a lot and this is not what
we want you to do for endo for obvious reasons. A Class I lesion on a molar/premolar is
very superficial. Still, local anesthesia is a very safe medication for a person- normal
healthy person - adult, you can give up to, if needed, up to 12-14 carpules without even
thinking twice [about] whats going to do this medication to the body. Now, we wont
give that many, but this is the amount thats a safe amount- thats a maximum dose that
you can give. And in 99% of cases, you will be able to do a RCT on a most difficult
tooth with only 2 carpules. Or a maximum 3. But please dont give half a carpule.
Dont give 1 carpule. I mean, 1 or 2, trust me does not have any effect on the healthy
patient but you would make your life easier, you want to make the patient more
comfortable. And you dont want that disruption in the middle of a treatment. It hurts a
little bit and thats going to be a real bad experience for the patient that feels what youre
doing. Even though youre taking care of it- youre taking care of it, youre giving local
anesthesia later on, you put in the patient comfort. But they remember well he was
working but I felt when he was filing the tooth and thats not what you want to be
known for- for when youre working on the patient they feel what youre doing. So again,
1
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
I just really want to emphasize this. When you get to the clinic in the near future, its
minimum 2 carpules we want you to give for any given tooth. And that, you will be safe.
And most of the time that will be enough. Sometimes you need more but. So thats the
introduction. Anyways, for local anesthesia.
[Slide 2] [History]
[Dr. Malek] So this is, were going to go over a little bit of medical history and the
history of the patient because it matters. I know in your DNT and also in your primary
evaluation of the patient, you need to go over the history. Right? You have to see what the
patient is taking, the medical/ dental. You may not really think that this has something to
do with success or failure of local anesthesia. But actually it does. So there are a few
elements in local- in the history that may have an effect. Anxious patients, this is
something that you need to record. Patients that are afraid of dental treatments, that I
think you will encounter a lot in the clinic. And these are the ones that you may want to
consider giving more local anesthesia. It has been shown that these patients are a little
more resistant. Red haired patients. Yeah. As we, right true. Some of you may think,
well, mean maybe. But thats actually scientifically proven. Theres a gene that controls
the color of their hair. Its the same one that has something to do with local
anesthesia resistance. And its actually something to notice. If you have- and theres also
something to do with the gender of the patient as well. If you have a woman, red
haired, there is likely that this patient would be more resistant to local anesthesia
than another person. Patients reporting previous problems with local anesthesia.
Again, what I am saying here is just not anecdotal. These are science that has been done
on them. When a patient tells you you know, youre going to do a local anesthesia- an
operative or endo one on my tooth but the previous dentist that tried this, he needed to
give 5 or 6. I still felt it. I know what youre thinking when somebody tells you this.
Well it was that dentist. Im much better than that. Dont worry. Ill take care of you.
But trust me, its not that much different. If somebody tells you Ive had difficulty
getting anesthetized give double the amount that you would usually give because
that would be the case with you as well. Medical history. Well, medical history, that
would be something to do with the amount of local anesthesia you want to give which
there are some limitations.
[Slide 3] [Adverse drug reactions to local anesthesia]
[Dr. Malek] And that brings us to the adverse effect. Adverse reactions of local
anesthesia. So there are many rules out there. If you look at the books, there are many
ways to calculate how much you can give and Im sure in other lectures, you have been
given those. And Im not going to be talking about that in detail but I believe the slides
that you have receiving or have received-have [you] received the slides of this lecture?
You have? Because, last night, I gave it to Dr. Busch so. You may have 1 or 2 extra slides
that I have not incorporated into this and that would be some information that you need.
Again, this is something that you need to consider. But for lidocaine 2% with 1:100,000
epinephrine, we know that its not going to be that big of an issue. Or if youre giving at
2
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
least 10 carpules, and again you would never, I mean, I said never, its a very rare
occasion. But this is one of the rules, 1:25. This is something you do with ANY
cartridge. You would be safe if you give 1 cartridge for every 25 pounds of patients
weight. And if you dont remember anything, if you go with just this calculation, at least
you know youre safe. And we know the maximum dose.
So 500 mg from non epinephrine is actually less than epinephrine contains. So this is an
important, its the second bullet because if you have a lidocaine with epinephrine, you
can give up to 500 mg, but if youre not having epinephrine, that will drop down to a
little more than half. That means if youre using carbocaine, I will have another slide,
cabocaine or mepivicaine, right? You have that in the clinic, you will see it. That local
anesthetic does not contain epinephrine and you think its safer but actually its not
because you cant give as much as you could give with epinephrine containing local
anesthesia. And the reason is, there is no constriction of the [couldnt hear] cells so that
would be washed out in the body faster. You have to be more careful with that. And for
cardiac patients, with epinephrine, we want to limit it to 1-2 cartridges. And theres a
lot of formula behind it. I mean, you dont need to do the formula, at least for the purpose
of my lecture. But just know the numbers. And with the possible exception of
mepivicaine and prilocaine - I dont think we have it here, in this country. But most
local anesthetics include some degree of vasodilation. Thats the reason. Most of them
are vasodilators. So keeping in mind the last bullet. If you have mepivicaine, and you
have lidocaine without epinephrine, actually lidocaine without epinephrine would be
more toxic than mepivicaine because at least mepivicaine is not vasodilator but
lidocaine is. So thats what you want to keep in mind.
[Slide 4] [Adverse drug reactions to local anesthesia]
[Dr. Malek] So going back to mepivicaine or carbocaine that youre going to have in
the clinic, is associated with a number of local anesthetic toxicity so you have to be
careful with that. And the maximum number of this local anesthetic to give an adult
patient with 150 lbs almost, would be 7 cartridges. So its a little more than half the
amount you can give with lidocaine. Again, Im just pointing it out that you may think,
in general, mepivicaine is safer in certain cases, yes. But you just have to know how to
use it because otherwise, it would just be more toxic.
With children, so we just really like to go with lidocaine, 2% lidocaine with 1:100,000
epinephrine. And we dont like to give carbocaine.
[Slide 5] [Chart]
[Dr. Malek] And this, you can look at later. This is basically the different kinds of
anesthetics available with or without vasoconstrictors. We dont have all of them in the
clinic but after a while, youll just remember the color. And the color is important
because you dont make a mistake. If the patient then needs carbocaine, you give a local
anesthetics with epinephrine, thats going to possibly be a disaster. And you have the
maximum allowable dose. So you see for lidocaine, the first row with 100K epinephrine,
which is red, which is the most cartridge that you are going to use is 13. But if you go
3
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
further down with mepivicaine, its 7. And the third row, lidocaine plain is 8 and also you
can go further down. We dont have bupivicaine but articaine we also have. The last two
rows, gold and silver, in the clinic. And we talk about articaine a little bit more.
[Slide 6] [Possible adverse reactions]
[Dr. Malek] So these are the possible adverse reactions with patients that you have
to keep in mind. Congestive heart failure, impaired liver function, because there is
solutions that are going to be metabolized in the liver. And pregnancy. Remember
lidocaine and priliocaine, we dont have prilocaine, are category B. And the rest are
category C. Do you know what category B and C? So I have another slide, you can look
through it.
[Slide 7] [Category C drugs]
[Dr. Malek] These are category C and B. So category C, it means that animal studies
not demonstrated fetal risk, but there is no studies in pregnant women. But category C
shows that animal studies have revealed adverse effects. So really for pregnant women,
you dont want to use category C definitely if you have a chance. And lidocaine is
safer than mepivicaine. I see a lot of patients coming in and they want to tell you that I
like to have mepivicaine given to me and you say why is that? Well the patient says
my OB/GYN suggests it that you go with mepivicaine or carbocaine because it doesnt
have any epinephrine. But we know for a fact that lidocaine is safer for pregnant
women. In these cases, you have to contact the physician. Maybe there is something else,
that you have to avoid lidocaine. But just don't go with the suggestion that the patient
tells you because it has more adverse effects and its to the fetus. So we went over
Category B and you dont have to know what Category B and C is, just , that was to
show you the level of risks that are involved with each one of these medications.
[Slide 8] [What is the blood pressure cut off point for the use of vasoconstrictors?]
[Dr. Malek] And thats the absolute no vasoconstrictor. If the 200 mg systolic or 115
diastolic. Now, many of the cases you wouldnt even treat in the clinic but these are the
cases in the instance where you have to do something in the case of emergency. You see
how high it is, 200mg and 115 diastolic, that means really that epinephrine in the
cartridges are not that much problematic in most patients. We just have to keep that in
mind. If the patient is in the chair, really in huge emergency, they just cant deal with the
pain and its beyond that, you want to go with carbocaine if possible. Never use
lidocaine with epinephrine.
[Slide 9] [Topical anesthesia (20% benzocaine)]
[Dr. Malek] And you all have topical anesthesia, I believe, in the clinic, yes.
[Student] Whats the main difference between carbocaine and mepivicaine?
4
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Dr. Malek] No, its just a brand name and generic name. Right, sorry, Im just using
them interchangeably. So topical anesthesia is that benzocaine 2%. Im sorry, 20%. Its
a kind of gel that you put on the tissue. And a lot of people dont use it. There are some
studies, actually, on the effectiveness of this gel. First of all, it doesnt show to be that
much effective in the inferior alveolar nerve block, thats the IANB. In maxilla, in
some people, it shows that it is is effective but it needs at least one minute. So if you
want to use it, fine, but at least leave it just for 1 minute. If you remove it after 30
seconds, its not doing anything. But interestingly, a lot of studies have shown that its
more psychological than clinical. And they have used other pastes that have nothing to
do with local anesthesia. Patients felt comfortable as well. They say yeah, its fine. I
dont feel that much pain. But it wasnt any local anesthesia that you used. I mean,
topical. So its up to you. You dont have to use it. If you feel that its giving more of a
psychological ease of the patient, you can absolutely use it but for some people, its not
that much of an important part of local anesthesia.
[Slide 10] [3% Mepivacaine (Carbocaine)]
[Dr. Malek] So lets go back to Mepivicaine 3% that you have in the clinic. We talked
about it. It will be washed out of the tissues very fast because it doesn't have
vasoconstrictors. So the duration is very short. Now if you want to use it, you have to
know its indications and how to use it. So if youre using for the maxillary teeth, after 20
minutes, sometimes maximum of 30 minutes, you wouldnt have anymore anesthesia
in that tooth. So if youre doing, I dont know, a RCT on a molar, definitely, you would
not be done after 30 minutes. So you have to keep in mind that you may have to give
more. And dont be surprised that the patient feels pain a little bit in the middle of a
treatment. But for IANB, its the same. So its only short duration for infiltrations, not
for blocks. And its as effective as lidocaine with 1:100K epinephrine. So for blocks, it
doesn't matter which one you use. Its going to have the same effect and same
duration. In this study, they did it on reversible pulpitis, but theres another one they did
with normal so I just combined the both. It doesnt matter the state of the tooth. You can
use either one of them. And theres another technique that were gonna talk about it.
Thats PDL ligament injections. Do you know what that technique is? Have you been
no? So, there is, you know, you have lectures on block and IANB and infiltrations? That
at least you know? Right? No? Ok. So, Im going to go with what I have and I hope, if
not , you will be given. Because, so this is, so there are many techniques in how to
anesthetize the tooth. A block is to block the trunk of the nerve and the other one is
infiltration. Its right next to the tooth. Its when you give a shot next to the tooth and
anesthetize the tooth. Now, interligamentary or PDL injection is that when you take
the needle and push it in the PDL between the tooth and the gingiva and then inject
the local anesthetic. And in this cases, its not an infiltration, its not really a block.
And its been shown that in these cases, you need to have vasoconstrictor, otherwise it
would not be as effective.
[Slide 11] [4% Articaine with 1:100.000 epinephrine ]
5
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Dr. Malek] And then you have articaine in the clinic. So when you go back, you have
lidocaine, mepivicaine, and then you have articaine. And articaine is 4% with 1:100K
epinephrine. And its shown to be very effective. So articaine is actually a very good
local anesthetic for infiltrations at least. And thats actually my local anesthetic of
choice. I can give blocks, as we talked about, with anything- mepivicaine or lidocaine.
But when Im going to give an infiltration, I usually go with articaine. But you can use
anything you want. But the point is, coming back to the point that I was making in the
beginning of the session is that if youre doing an endo on a lower molar, you want to
give at least 2 carpules. And that 2 carpules is not 2 blocks. Its one block with one
infiltration. And there are certain exceptions that were going to discuss. The block
could be, again, lidocaine or mepivicaine. But for infiltrations, again, we dont want
to use carbocaine because carbocaine, we talked about, is a very short duration. For
infiltrations, always use lidocaine, or articaine - epinephrine containing local
anesthetic. Unless we have a cardiac patient- thats another story. So articaine is
shown to be more successful in IANBs. So in general, its a good local anesthetic and
its been out for I guess 10 years. Its pretty recent compared to lidocaine or mepivicaine.
But the problem is the last bullet. If you ever go and buy, purchase this articaine in a
packet, when it comes out, theres an insert that gives the information of the drug. If you
look at it, theres a big red box over there on one of these instructions that warns you that
this medication, or this local anesthetic is associated with nerve damage in IANBs.
Now it has not been scientifically proven but there are some evidence. So, suggestion is,
with your blocks, try to give it with lidocaine or mepivicaine. Avoid articaine.
Although if you do it, its not going to be illegal but its just to be on the safe side.
And for your infiltrations that you want to give next to the tooth, try to use articaine or
lidocaine. Thats for the lowers. For the upper teeth, then we want to avoid mepivicaine
altogether because we talked about it. So go with lidocaine or articaine. Whatever you
want. Again. On last Thursday, cardiac patient or something else you should take into
consideration.
[Slide 12] [Success of maxillary buccal infiltration ]
[Dr. Malek] So buccal infiltration and maxillary buccal infiltration. Its a pretty good,
successful, 99-95% in anterior and posterior teeth. And when I say successful, I just have
to define this because you would say what does that mean? Is 5% of cases when you give
local anesthetics in an anterior maxillary, you wouldnt get pulpal anesthesia? Well thats
not true. The definition of success and failure in local anesthetic in scientific settings is
that if the tooth would respond negatively to electrical pulp tester 2x in 15 min.
interval for at least one hour. So this is the definition of the success of local
anesthesia. If you can anesthetize a tooth for one hour with confirming it with an
electrical pulp tester 2 times at least in 15 minute intervals. In 95% of cases, you will get
this. If you use any kind of infiltration other than mepivicaine or carbocaine in a
maxillary tooth. But not all of them.
6
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
So, again, if your procedure is around one hour, which I think most of the procedures are
not more than hour- at least operative. You should be fine. But if its more than an hour,
you have to consider maybe I have to give another carpule of anesthetic after like 15
minutes. And dont wait for the patient to report pain. Just give it if you think necessary.
And it takes about 5-7 minutes for the patient, the tooth to become anesthetized.
Now this number is important, 5-7, because you dont want to start immediately, you
have to wait a little bit. Dont expect to be anesthetized after 3 minutes. Now this is also
interesting that slow onset occurs in 20% of patients. So 20% of patients, 1 out 5,
would not be anesthetized in a maxillary tooth after 7 minutes. And these people may get
anesthetized after 20 minutes, actually. So be aware of it. Thats why when were dealing
with an operative or endo treatment, whatever it may be, in a vital tooth, actually, you
want to test the tooth, make sure that its anesthetized before going in. Dont assume I
gave local anesthesia. Its ten minutes. Absolutely the tooth is numb. In 20% of cases,
the tooth would not be done after 7-10 minutes. And it has nothing to do with you not
giving the anesthetics with the correct or right technique. So dont blame yourself. I may
have done something wrong. Yeah, you may have done something wrong, but not
necessarily. A lot of patients, they will not get numb. And in anterior teeth. You know,
actually in the posterior teeth, we will have better local anesthesia duration. In
anterior teeth, it seems to be starting to decline after 30 minutes. But when it starts to
decline, it doesnt mean that the patient will feel it. It takes a while after the patient feels
it. But after 30 minutes, it will start to decline. And after 50 minutes, or maybe an hour,
the patient will really feel it. And, but the patient still feels anesthetized. The soft tissue
is numb but the tooth itself may not be. So this is another point I want to make.
Differentiate soft tissue numbness from the tooth itself. It has nothing to do with each
other. The tooth will be totally numb and the soft tissue, but the minute you touch a tooth
the patient may jump. So thats with infiltration.
[Slide 13] [Success of IANB]
[Dr. Malek] Lets go back to IANB. Which we discussed a little bit but a few points. So
the block on the mandibular nerve block doesn't have a very good success. You can
see, 50-60% in first molar and 10-35% in incisors. Its interesting. It means that if you
give one block, its around 50-60% chance that the patient would not be anesthetized on a
lower molar #19 or 30. If its an incisor, forget it. Forget it. Thats why for a lower
incisor, dont bother yourself with blocks. Dont bother. Just go with infiltration. And
with infiltration, you want to go with articaine or lidocaine. Even for endo, for the
lower incisors, thats how poor is the success rate. Now this is important- the patient will
develop some lip numbness after the block, I think you all have been taught that. So when
you give the block, because the nerve runs through the mandible, a branch comes out
of the mental foramen and just spreads around the lip. So if youve done the block
correctly, after 5-10 minutes, the patient will develop some lip numbness over here-
up to the midline. And a little bit of numbness in half of the tongue. This is an
indication that you giving the local anesthesia correctly. That means youve hit the nerve.
You did it right. But it doesn't mean that the tooth is anesthetized. Thats very
7
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
important. So achieving lip numbness is important because you know you did it right. But
it doesn't mean that the tooth is anesthetized. And, again, in the block, you will have to
wait sometimes 10-15 minutes. And, again, as we talked about infiltration, there are 20%
of cases that patients will not become anesthetized even after 10-15 minutes. These
patients will need like 20 minutes. So think about it. You have like 2 hours blocked,
right? If youre planning to do a RCT, youre going to seat the patient and bring your
stuff if youre not ready. If youre going to give your local anesthesia at- your time starts
at 2:00 because your like 2-4, right? If you give the block at 2:30, if this is one of your
patients, the patient will become anesthetized at 3. You gonna start at 3 when you know
youre going to close at 3:30 because youre going to get out of there at 4 and the faculty
is not going to be around. So you dont have much time. So these informations are
important for you to think about if youre doing an endo treatment on a tooth- just think
beforehand. Make sure that you have ample enough amount of time just in case this
happens. And I have to tell you. Most of you this doesn't happen, but if it does, its a
disaster because youre giving local anesthesia, the patient is not numb, its painful, the
time is up- you dont know what to do. Just set enough amount of time just in case the
patient is going to be delayed onset anesthesia.
[Slide 14] [Table 2-1]- SKIP
[Slide 15] [Table 2-3]- SKIP
[Slide 16] [How to assess the success of local anesthesia?]
[Dr. Malek] So how to assess the success of local anesthesia. So pulpal anesthesia
may not be present for mandibular first molar in 23% of patients despite soft tissue
anesthesia. But this is another study. See, in 23% of cases, the patients will tell you
well, Im numb. Half of my face is numb. But the minute you put the bur on the tooth,
the patient will jump. And this is confusing, right? Because you think, well, why is the
patient not numb. Because I did something right, because you know, the soft tissue is
numb. And this is why you always want to do a pulp testing with a cold refrigerant
or an EPT. If you dont have an electrical pulp tester, just get a cold cotton, put it on
the tooth if its a vital case. If its a non-vital case and the tooth was non-symptomatic, for
instance when you percuss the tooth- do the percussion. Make sure the patient is
numb. And the last bullet point is very important. In painful teeth, like irreversible
pulpitis, the lack of response to pulp testing may not guarantee pulpal anesthesia.
You see how complicated it is? Even if you do the pulp testing and the patient shows that
there is no sensitivity to ice, although it was before, still it doesn't mean that when you go
into the tooth the patient wouldnt feel anything. So, see how much prepared you have to
be? Now this is an endodontists point of view. Because as an endodontist, thats what I
have been trained and I know. I have to be prepared for any sort of pain during, before
and after the treatment. But I just want to warn you. Things do not really go the way you
8
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
have read theoretically. Dont think the lip is numb, the tooth is numb. You have to
do the pulp testing. Dont think the pulp is responding negatively, the tooth is numb.
There are a lot of other elements, this lecture wont allow me to go into too much detail
but Im just warning you- dont be confused as well. Dont think that this is normal,
this happens. You didn't do anything wrong. You did maybe everything right, but this
case is- and in these cases, you have to give some supplemental local anesthesia and
thats where the interligamentary or PDL injection and intrapulpal come into play.
And you have to know all of these techniques. So if youre starting RCT on a vital tooth
and you dont know how to administer a PDL or intrapulpal injection, its going to be an
issue. What if you need it? So I just want to make sure you be prepared before starting a
RCT on a patient.
[Student] inaudible- something about the pulp being completely numb?
[Dr. Malek] No, not in the cases of irreversible pulpitis. Im just giving you a little bit
piece of information because in these cases, the nerve endings are hyper sensitized so it
would be, they would be very sensitive and resistant to local anesthetics. But, only to
mechanical irritation. So they will not respond to cold because thats a thermal irritation.
But when theyve been hit by a file or a bur, thats a mechanical irritation that the patient
will jump. And when you get that, then you have to stop and give something more. Now
what would you give? Lets say the first stage, you gave local - you gave IANB and the
patient developed lip numbness. And then you put the cotton, cold, on the tooth and the
patient jumps. So what would be your next step. What would you give? Would you go
back and give another block? Right. Why wouldn't you give another block? Because the
block was fine. If the block was not fine, you wouldn't get lip numbness. Youre right.
But if after 20 minutes, the patient didnt develop lip numbness, you may not have hit
the nerve correctly. So youd have to give another block. So the only time, I want you to
know, that it is justified for you to give the second block is when the lip numbness is
not achieved. If that was achieved, you cant do better than that. Youll achieve lip
numbness. Youll have to go the local. I mean, both of them are local, you meant
infiltration actually. Because IANB is local as well. So you want to go with infiltration
with septocaine or actually articaine or lidocaine.
[Slide 17] [Prevention and Management of Local Anesthetic Failures ]
[Dr. Malek] So there are many ways to prevent and manage anesthetic failures. So,
again, were going to go back. Get a good history, make sure what kind of a patient
youre dealing with. That this patient seems to be a patient that would be resistant to local
anesthesia. Think about that. It may be- be prepared. Reduce the level of anxiety. That
helps a lot. You just have to soothe it down a little bit. Talk to the patient a couple of
minutes. The more comfortable they are that what youre doing is not hurting him or her,
the more they will be relaxed and will not be jumpy during the treatment. Select the
appropriate anesthetic. This is important. If theres no cardiac problems, dont give
9
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
mepivicaine or carbocaine on a maxillary tooth. And as an infiltration on a lower tooth,
even, dont give a carbocaine. It just doesnt make sense. Not only appropriate anesthetic,
the appropriate amount. Dont give half a carpule or even 1 carpule. Its just not
worth it. Its not really worth it. Just give 2. Even if its a maxillary tooth, just give at
least 2- especially in the lower. Lower, you have to- 1 block, 1 infiltration. Thats the
standard. Because we know, block we need it, but its only 50-60%. You need to give
infiltration. For the lowers, definitely. Even for the lower incisors, youre not giving a
block- two good infiltrations and youll be fine.
[Student] If our patient has heart problems, do you use carbocaine for the inferior
alveolar nerve for the lowers. And for the infiltration, carbocaine again?
[Dr. Malek] It depends, what kind of cardiac patient. Because for cardiac patients,
youre allowed to give 2. So I would save the 2 carpules for when I really need
epinephrine. For the block, it doesnt matter what you give so Im not going to waste
my epinephrine for the block. Because for the block, even if you give mepivicaine,
youre fine. So for the cardiac patient, I would give the block with mepivicaine, right?
And with the same thing, get lip numbness, check the tooth. Then for infiltration, I can
give one carpule of lidocaine. Unless, in your medical consultation, the physician
really warns you not to use epinephrine at all. Then its going to be a little more
difficult because you have to give infiltration with mepivicaine, but you know its not
going to be as effective so you have to be aware of that.
And you have to know adjunctive drugs or techniques. For drugs, I mean, sometimes
you have to give, if its an infected tooth, is a inflamed tooth- sometimes an anti-
inflammatories or, you know, anti-microbial would help sometimes before going and
doing a treatment on a tooth. These are things to think of.
Using supplemental local anesthesia. Were going to talk about it a little bit. But lets go
through this.
[Slide 18] [Which of these strategies work for increasing the success rate of IANB?]
[Dr. Malek] So which of these strategies work for increasing the success rate of
IANB? Now, increasing the volume of lidocaine to 2 cartridges. Increasing the
concentration of epinephrine because you know you have 1:100K, and you have 1:50,000
epinephrine. So you know we have 2 different cartridges of lidocaine. We can use either
one. And use a supplemental anesthesia. Which one do you think? Its C. Increasing the
volume, no. If, your success rate would not increase by doubling it. Its just again,
volume doesnt have a role in this. Concentration, it doesn't matter. If you give 1:50,000
or 1:100,000 - epinephrine doesn't do anything with blocks. Again, it does something
to do with infiltration, but not the blocks. Use a supplemental. A supplemental is
always the first choice of infiltration on the lower.
[Slide 19] [Attention!]
10
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Dr. Malek] Now remember, if the patient has profound lip numbness and
experiences pain upon endodontic access, repeating the IANB does not help the
problem. You need to know what to give as a supplemental. And clinicians may think
another injection is helpful because the patient sometimes receives pulpal anesthesia after
the second injection. And this is something that a lot of you may experience. But the
patient may simply be experiencing slow onset of pulpal anesthesia from the first
injection. So I talk to people and they say well, this is not true. The patient has lip
numbness and the patient is sensitive when I touch the tooth. But when I give another
block, then the patient will be fine. Its shown that this is not true. If you had not even
given the second one and had waited another 10 minutes, the patient would have gotten
numb and you could have gotten into the tooth. So, its not the second block thats
working. Its actually the time that youre waiting.
[Slide 20] [Which of these strategies work for increasing the success rate of maxillary
buccal infiltration?]
[Dr. Malek] So we talked about the mandibular is always another local anesthetic,
another infiltration will help. For the maxillary, which of these strategies work for
increasing the success rate of maxillary buccal infiltration? Same choices. Increasing
the volume? Increasing the concentration? And use of supplemental. Which one?
Actually, for maxillary, all of them. If you give two, its going to be a better local
anesthetic than one. If you increase the concentration of epinephrine, its still going to be
better because its not going to be washed out that fast. 1:50,000 will stay in more than
1:100K. And of course use of supplemental. So you see, if you know exactly the
anatomy, the biology and also the drugs that you are dealing with, you can select the
appropriate type and amount of local anesthetics for each single case. Each one of them is
different.
[Slide 21] [Supplemental LA Periodontal Ligament Injection]
[Dr. Malek] So periodontal ligament injection. Again, its the case that you put the
needle between the tissue and the tooth and push it in very hard. Then you inject a
couple of drops. Because its a very tight environment. Its very tight, the tissues. You
dont have that much space. And just a couple of drops will do. And thats when the
infiltration fails. When the block fails, the infiltration fails, theres no other option to
do- that would be your third choice. In the maxillary as well. The infiltration, 2
carpules. For some reason the patient is still feeling pain and you will have these cases, I
have to tell you. Giving the third and fourth, thats not going to work usually. So its better
to change your strategy and use another technique. And in these cases, a PDL injection
would be the choice. So it is an important type of intra-osseous injection. It will
increase the success of the block for another 20 minutes. But it means that you have
just a short duration of time to get rid of that inflamed pulp. You have only 20 minutes.
You have to be fast, remove it. Otherwise, it would just fade away.
11
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
The problem with this injection is the patient will develop some post-op discomfort.
And thats part of it. And when I say discomfort, its not that its severe pain. But theyll
say you know, its painful when I bite on that tooth. And theres always ways to avoid
that. I mean, not avoid it, but to eliminate that discomfort. And the most important
way to eliminate that is to just cut down the occlusion. And you know, for RCT, thats
the first thing that you do. Unless its a crown and unless its a central tooth where you
cant cut down occlusion. But in premolar, the first thing is get it out of occlusion
regardless. So its not really that serious but it is something. If the patient comes back oh
I have a little bit of discomfort especially when I chew on it. You can say well, please
dont chew on it and for different reasons. Because I have a temporary filling and the
filling would come out. Thats not going to be a problem. You can get pain medication
and the patient should be fine. It should be associated with back pressure. It means, that
when youre injecting for instance- have you tried it at all on yourself perhaps, the
anesthesia? So if youre giving like an infiltration or a block, theres no back pressure.
Its not that you have to push it. Right? Listen, if youre pushing it in a block, youre
doing something wrong. Dont do it. Its just soft tissue. Its just a little bit of pressure, it
should just flow in. Thats not the case with this technique. Its- you need a little bit of
pressure and its just a resistance. But when youre getting your resistance, it means
that youre doing it right. So its just the opposite. In a block, if youre getting
resistance, then, you know, youre somewhere that youre not supposed to be. But in
this case, if theres no resistance, it means youre just flowing out to somewhere else. So
you have to feel the back pressure. And you will have immediate response. There are
two injections that have immediate response. This is the first one of them. The rest,
infiltration is not immediate. Block is not immediate. So immediately, you will get
anesthesia. You can start right away. Thats how great it is. At least at this aspect. And
again, its not a limitation with vasoconstrictor. Please don't use carbocaine. Again, our
anesthetic of choice is always epinephrine containing local anesthesia. Lidocaine or
septocaine, articaine. Dont use them if its contraindicated. But if it doesn't really
matter, just use it. Yeah, I mean sometimes its not really as effective in your anterior
teeth PDL because the PDL is a little bit wider in the back teeth. And in the front, its a
bit more difficult. But still, its something you need to do if youre not developing
profound local anesthesia.
[Slide 22] [Supplemental LA - Infiltration]
[Dr. Malek] So again, the main injection method in all maxillary teeth is
infiltration. And in the mandibular anterior teeth, we talked about it. Even in
premolars, you can use infiltration alone. But if youre using it for a central incisor,
lower, or a premolar, again- absolutely, you have to give two full carpules. Because,
again, the mandibular bone is thick cortical bone. You know, its not the cancellous
so you have a little bit more difficulty penetrating. Always give two. But. And the
reason we are suggesting giving infiltration in central and sometimes first premolars is
that the success rate is so low with the block. It just doesnt work as well.
12
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Slide 23] [Supplemental LA Intra-pulpal]
[Dr. Malek] And this is the last technique- the 4th one that were going to talk about
and its intra-pulpal. So intrapulpal is when you have a vital case. You manage to get
into the pulp, right? And when youre touching the tissues, the patient is feeling
pain. So you passed the first, second test- you managed to get into the tooth but now the
patient is not really sensitive. And we talked about there are instances of mandibular
posterior teeth, reversible pulpitis that even supplemental would not work. So, the block
doesnt work, the infiltration doesnt work, the PDL injection doesnt work. So
three strategies failed. That is your 4th. Thats your 4th. It will give you around 15
minutes of time just to do what you have to do. Otherwise, it would just come back
again. And its a pressure induced injection. This is different than associated with
back pressure. Its not usually- it may or not be associated with back pressure. But its
pressure induced. It means whats working- its not the type of liquid. Its actually the
liquid going in with pressure so even if you would use water, it would still work. So its a
pressure that is anesthetizing the tooth. But again, please dont use water. Use the local
anesthetic that you have. But what Im saying is that whats causing it is the actual
pressure thats being induced. And its extremely painful. Thats why its your fourth-
maybe your last resort. We just dont want to start with- we don't want to give
intrapulpal unless interligamentary and infiltration have failed. The patient will feel it.
But the technique to do it is that you have to tell the patient that it will take a few
seconds, deep breath. And dont stop in the middle. The patient may scream, but dont
stop. Because if you stop, the patient has felt it and the injection has failed and you have
to do it again. So let the patient scream only once. So thats the point I want to make.
Again, its painful but thats how it is. In very rare instances, thats what you have to do.
And still, the patient feeling this pain of injection is much better than not giving this
injection and having pain all along. And the patient will forgive you. Trust me. Because
they know its not your fault. But if you dont give this injection and the patient feels
even the low grade of pain when youre doing the filing, they will not forgive you.
Because, theyll think you could have done something. But this is what you can do.
Youre trying to help the patient but the procedure is painful. They are two different
things. So dont worry about it and the patient will understand. And again, its not your
fault. Who knows whose fault it is? But thats how it is. You have to do it. And again,
warn the patient just a couple of seconds, Im going to give an injection. Its going to be
like a pinch and youre going to be better now. And just talk to the patient as youre
doing it. Are you still feeling it? Are you still feeling it? After two seconds, the
patient will say Im not feeling anything. And again, you have 10-15 minutes.
Dont give the intrapulpal and say oh shoot, I have to get my files. Ill be right back.
When you go back, when you come back, the patient is still in pain again. You have to do
it one more time. Get everything ready, know what youre going to do when the patient is
going to be numb. I know that in minutes Im going to give this injection. Im going to
use this block and Im going to do that. Be prepared, because you dont have much time.
[Slide 24] [Thank You! ]
13
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Dr. Malek] Is that it? I guess it is. Any questions? So we did well.
[Student] Could you explain again, whats the reason when youre doubling the
volume of the carpule in the block. Why is it not increasing the ~Cant hear. Asking about
the effectiveness?~
[Dr. Malek] Because. So this is- so the assumption is, again, if youre getting it right
the first time- this is the assumption, good question actually. That needed an explanation.
In the maxillary, even if youre getting it with the first which you are, the second
would actually help more with the duration. So it helps if you get three or one in the
maxillary. But in the block, it doesn't matter. It wouldn't increase because either
youre getting it or youre not getting it. If youre getting it, giving a couple of more
would not really do anything. So if the first one that youre giving, you get lip numbness
but falls within that 50% of although lip is numb, the tooth is not numb. Giving the
second one would not increase that. Its depending on a lot of other factors thats not in
your control. Its the anatomy, the physiology of the biology of the area. So just dont
waste your carpules because of that. You did your best, and thats the best you can get
with that patient. Thats what it is. Lip is numb, the tooth is numb to some degree. Now
just move on and don't waste your time. Move on to the next strategy you have.
Infiltration. And again, repeating it. If you dont get lip numbness after 10-15
minutes, sure, give another one. And usually give a little higher- maybe you missed
the nerve or something like that. Didnt you raise your hand?
[Student] Well I did but I decided it wasnt really worth it.
[Dr. Malek] Yes.
[Student] With intrapulpal injections, if you know its going to take more than 15
minutes to do what you have to do, can you give them another one after 10 minutes
while theyre still numb?
[Dr. Malek] Actually, thats a good- I dont know. You can try. I don't remember
reading any studies on this but it sounds logical that it may. But usually theres one canal
in a tooth that is very stubborn. In a multi-rooted tooth, like a molar. There is only one.
Sometimes. Its a distal of the mesiobuccal that is really giving a problem. Removing the
nerve, really doesnt take that much time. Dont think that you have to instrument the
canal. Just removing the pulp. Thats using 2 or 3 files and irrigating and taking it out.
So, Im just saying, if youre doing what you have to do, 15 minutes is more than enough.
But just do it. Dont give it and go and ask the faculty to come over because that takes..an
hour sometimes? So dont do that. But sure, if you feel that the patient is still- and it
doesn't come back immediately. Its not that the patient will become all of a sudden more
sensitive. Gradually the patient will feel what youre doing and you can of course
give another one. Yeah. Sure. Do it and let me know how it works. Sure.
14
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
[Student] With a pupal injection, you wouldnt want to put too much pressure on
injecting it, right?
[Dr. Malek] I want to put too much pressure.
[Student] Why?
[Dr. Malek] Well why wouldnt I? Because its the pressure thats anesthetizing the
tissue.
[Student] Right, right. But wouldnt you kind of push all of that necrotic tissue
deeper into-
[Dr. Malek] Ok good question, but the problem is, if its a necrotic tooth, you
wouldnt do intrapulpal because theres no pulp. If- usually in necrotic tooth, when
youre instrumenting and the patient feels the pain, its usually in the apical portion
because, you know, the tooth is not a black and white thing with necrosis. Necrosis has
gradation. It starts from the vital tooth to the completely necrotic tooth. A tooth with
possible necrosis falls somewhere in between. And necrosis starts from coronal all the
way down to apical. So you may be dealing with a possible necrotic tooth which has
vital tissue in the apical 1/3. Thats where youre feeling it. So its not 100% necrotic
tooth. But if its a tooth with periapical lesion, theres no vital tissue in that tooth
because youre right, youre just pushing everything out. So in those cases, actually,
interligamentary would be the best because they would anesthetize the tissues from
outside and thats where the pain is coming from. Not from inside the tooth. Another
thing. If you think that the patient is feeling pain when youre instrumenting the
canal in the apical portion, just double check your working length. Maybe youre
out of the apex. So before anesthetizing the patient, just question yourself. Maybe Im
not in the place that Im supposed to be. Because intrapulpal usually anesthetizes the
pulp, but not the periapex. So even though you give intrapulpal, if you go in the
periapex, the patient may feel it. And thats a good indication that maybe youre out.
Just take an X-ray. So pain is actually not a bad thing. It gives you an indication of
where you are. We dont want too much of them but, you know, sometimes, it just helps
us as well.
[Student] Can you explain more about the difference between maxillary and
mandibular? You mentioned that epinephrine is needed for the mandibular? Its better? So
is that-
[Dr. Malek] No. For infiltration, you need- for infiltration anesthesia, you need the
anesthetic to contain epinephrine. Because otherwise, it will be washed by the body. So
in the maxillary tooth, thats the only thing we have. We have infiltration. So for
15
Transcribed by Charles Buchanan Date of the Lecture: 10/17/14
maxillary, we dont want to use mepivicaine or carbocaine. Unless its
contraindicated. But for the mandibular block, apparently this doesn't work this way. It
doesnt work this way. Even if you give a block with mepivicaine, you still have the
same amount of success as if you have given lidocaine with epinephrine. So if youre
giving a block, and youre telling me what should I give it?, I don't really care. Some
people may care if you give articaine because it may cause, you know, paresthesia. But in
general, whatever you give, its going to work. Bottom line. But for infiltrations, try to
give with epinephrine. And thats the difference between maxillary and mandibular. Ok.
Good luck on the exam. Thank you.
16