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1. OPERATOR-DEPENDENT FAILURE
Factors in this category have no physiological/
pharmacological basis but are the most common cause
of failure, almost always with inexperienced operators.
Incorrect positioning of the needle, e.g. during an ID
block, could involve depositing LA solution too near in
the medial pterygoid muscle or too far into the parotid
gland, thus missing the target. Failure to touch bone at
the right location and depth will not ensure that the ID
nerve has been targeted successfully. Local anaesthetic can
be injected intravascularly with the entire drug being carried
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2. PHARMACOLOGICAL FAILURE
This situation occurs rarely and could be due to the LA
drug being out of date or not strong enough to achieve
effective anaesthesia. But pharmacological failure usually
concerns vasoconstrictors.
A vasoconstrictor (usually adrenaline) is used alongside
local anaesthetics. It acts to constrict local blood
vessels, reducing bleeding and prolonging the time of
action of the LA drug. If a vasoconstrictor was contraindicated (e.g. in cases involving severe arrhythmias or
osteoradionecrosis of the jaw) then the efcacy of the
local anaesthetic may be reduced as it may be washed
away rapidly and its elimination through diffusion
into blood vessels may be increased. The duration of
anaesthesia will therefore be signicantly reduced when
using plain solutions, and such solutions may therefore fail
to provide complete anaesthesia for the whole procedure.
Finally, there are two types of LA drugs available: esterlinked and amide-linked. Esters are metabolised locally by
plasma and tissue esterases, while amides are metabolised
in the liver. Esters therefore have a shorter half-life and
duration of action. For this reason, ester LA drugs such as
Procaine may again fail to provide complete anaesthesia
for the whole procedure.
3. PSYCHOLOGICAL FAILURE
Fear, phobia or anxiety will increase the patients pain
threshold. This will often present clinically as the patient
interpreting pressure or cold air from instruments as
pain, even with a successful nerve block or inltration
anaesthesia10.
4. ANATOMICAL VARIATION
This refers to the variable positioning of foraminae (and
therefore nerve trunks) between patients. For example,
the mandibular foramen is commonly more superior in
position than usual10, resulting in local anaesthetic being
deposited below the nerve trunk with no regional block
obtained. The mental foramen is also variable in position,
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Figure 2
2. MANAGEMENT OF PSYCHOLOGICAL
FAILURE
A calm and reassuring manner on the part of the clinician
is appropriate in most situations. However, in cases of
more severe anxiety, IV sedation, e.g. with midazolam,
can be used to good effect. Dental phobias require
treatment under GA or referral to a specialist phobia
clinic.
3. MANAGEMENT OF PHARMACOLOGICAL
FAILURE
Firstly, the clinician should always check the expiry date
of the LA drug.
If a stronger drug is needed, then 5% lidocaine with
adrenaline is usually effective, or articaine can be used
for its excellent diffusion properties. When adrenaline
is contra-indicated then Citanest (3% Prilocaine + 0.03
IU/ml Felypressin) is very effective. When forced to use a
plain LA solution then Scandonest (3% Mepivacaine) is
the most effective. Ester LA drugs should be avoided at
all costs.
4. MANAGEMENT OF ANATOMICAL
VARIATION
An OPG can be used to locate the mental and
mandibular foraminae. Inltrations mesial and distal to
the zygomatic buttress will overcome its effect as a barrier.
Posterior mandibular inltrations should be conducted
with articaine because of its excellent diffusion properties.
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BIBLIOGRAPHY
1. Blair and Erlanger 1939.
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