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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Anaesthesia problems

From: "Fred Barnett"
Sent: Wednesday, April 04, 2001 7:24 PM

Colleagues have recommended Articaine, and have even said that if you
give an infiltration for a lower molar, it will get numb.
REALLY?!@#?  An infiltration?

Does anyone have experience with Articaine for those tough to anesthetize
"hot" lower molars?
Have there been any complications associated with this anesthetic?

From: Guido Costa 
Sent: Thursday, April 05, 2001 08 01

Greetings Fred, I think there have been some reported cases of paresthesia
after IAN blocks. I'll have to look for the articles....

BTW, send my regards to Dr. Hicks..., he spoke very well about you when we
were discussing periapical bacterial plaque at the meeting. - Guido

From: Fred Barnett 
Sent: Thursday, April 05, 2001 08 08

Thanks Guido!

I'll give Dr. Hicks your regards.  I also heard of the paresthesia, but was
not aware of the exact incidence. - Fred

From: Yosi Nahmias 
Sent: Thursday, April 05, 2001 04 02

I have been using the stuff (Ultracaine ) for 15 years. NO PROBLEM MAN!

From: Benjamin Schein 
Sent: Thursday, April 05, 2001 08 20

Fred:

I have an assistant on Mondays that works with a good GP in a neighboring
town, She has 20 years experience and very smart, by the time I get to
the patient she has diagnosed him/her and knows exactly the difficulties
of the case. She claims that her doctor -the rest of the week- used to
miss a lot of blocks until Articaine came along. With Articaine he rarely
misses.

On the other hand I heard Ken Hargreaves (in Einstein biologic review)
talking about a Canadian retrospective epidemiological study done  actually
in Toronto by Has et al. in which the investigators found a higher rate of
paresthesia with Articaine and Prilocaine. Canadians and Europeans have been
using Articaine for a long time. Based on Hargreaves admonition and after
reviewing the Has study, retrospective and with some statistical flaws,
the reasoning was strong enough to make me  stop using Citanest Forte for
blocks but still use it for infiltration. Malamed recently published in the
ADA a multi-center study with Articaine. He did not confirm the findings
by Haas et al. But the study was done with the help of Septodont
the manufacturer.

From: Dave Deeley
Sent: Thursday, April 05, 2001 08 46

Ben:

The original Articaine formula in Canada was from Hoescht (sp?) and
included preservatives that would not allow it's sale in the U.S.A.
Methylparaben was one I recall.  They also had enough political clout to
force Septodont to go through many tests that they did not go through to
sell an Articaine w/o the preservatives.

Dave

From: "Joseph A. Belsito"
Date: Thu, 5 Apr 2001 09:43:30 -0400

Greetings to all , I've been lurking and thought I'd jump in.
I've been using articaine for about 10 years and I love it!  During the
first 5 years of practise (pa--->>pre-articaine days) IAN blocks were hit
and miss (about 10% miss) but since then <1%.

As far as paraesthesia, this is a tough one. There is a documented problem
of persistent paresthesia/anesthesia when certain local anesthetics are used
in the mandible overall.   These are prilocaine and articaine. Dr. Dan Haas
(UofToronto) did the study and I discussed it with him a few years back now
on another dental group.

The thought here was that the 4% solutions were the cause, Prilocaine
(Citanest) is sold as a 3% solution ..maybe the higher concentration are
neurotoxic to some individuals. I've never had a problem myself, however the
observed frequencies of paresthesia following the administration of
articaine (p < 0.002) or prilocaine (p < 0.025) were significantly greater
than the expected frequencies for these agents if I recall correctly.  But
this translates roughly 1 in a million chance---is this clinically
significant?

Joseph A. Belsito
UWO 87

No, just legally significant. - Joey D

From: Kachman
Sent: Thursday, April 05, 2001 12 24

There is no way in the world you can simply infiltrate for a lower molar
with articaine and expect any kind of anaethesia...it is excellent for mental
blocks(if there is such a thing)...for work from 35-45 (#s 20-29) I seldom use
anything but a mental nerve injection...in my opinion the septodont version is
just an ultracaine wannabe

From: David Mee
Sent: Monday, April 09, 2001 23 05

Sorry - but I didn't believe it until I tried it - had someone just in -
lower second molar - buccal infiltration - when he came back from waiting room,
without prompting he said "My lips numb so its worked" - and it had! I always try a
buccal inf first now and warn them to let me know if they want an ID - usually if
there is any sensation they opt for carrying on rather than the ID :-) - David
From: Mark Dreyer Sent: Thursday, April 05, 2001 18 33 I've heard a lot of anecdotal reports of infiltration success on lower teeth with Articaine, but no studies showing this to be true that I'm aware of. I did a small direct composite on a local dentist a couple weeks ago. It was a lower premolar. She refused to let me give her a block-she requested infiltration. I accomodated her in this request and she did fine-said she didn't feel a thing. I used lidocaine. Of course this didn't prove anything to me, but I found it interesting nonetheless. There have been well documented cases of paresthesia when using 4% local solutions for manibular blocks, so I'd not use Articaine for a mandibular block. Consider the Gow-Gates, or Akinosi blocks when having difficulty with a hot tooth. Also, if you aren't doing so already, switch to 25 guage long needles. This alone will increase your success rate in IANB injections-mostly due to less deflection from the stiffer needle. Mark Dreyer, DMD, PA Where to find a more in depth description , maybe photos of the Armanasco-Suers technique. Thanks, Danny
From: Molar Del Sud (Ace Dentura) Sent: Thursday, April 05, 2001 19 08 I'm looking at the pamphlett/brochure and I can't find even a phone number....now wait ..it's John A. Armanasco 602 Stirling Highway,Mosman Park,WA.6012 Phone OZ 61 093841222
From: Molar Del Sud (Ace Dentura) Sent: Thursday, April 05, 2001 15 57 I use a variation of this technique.......supplied to me by Jon Carna,which is a pretty close technique http://www.comfortdent.com . BTW I couldn't get used to the rubber thimbles......plus I also saw legal problems if you stick your nurse with a needle...still for A$68 the technique is worth learning "There is an infiltration like technique called the "Armanasco-Suers" technique. It is a trans alveolar intraseptal injection technique. I use whatever technique I need to get anaesthesia, don't we all. The A - S technique involves crushing the, say, lingual papilla of tooth 46 and then placing the LA needle ( ultra short 30 gauge ) at the base of the triangular buccal papilla, at 20 degrees from the axis of the tooth. As you inject the LA the lingual papilla seems to enlarge, you can feel the solution moving through. As you lift your finger off the papilla the presumption is that the elasticty or rebound in the tissue "sucks" the solution through. In the process the cancellous bone acts as a conduit to the dental nerves and anaesthesia is instantaneous ( and, in my experience, short lived but enough to get into the pulp. Chemistry is fine, but if we don't put the drug by the nerve anaesthesia is less likely ). If you do the technique correctly and carefully there is no risk of moving through to puncture your finger on the lingual aspect of the tooth. A sterile thimble can help to simultaneously apply the necessary force and protect the digit from needle stick risk. " Molar Del Sud is Australia From: Garry Nervo Sent: Thursday, April 05, 2001 15 35 There is an infiltration like technique called the "Armanasco-Suers" technique Try it. Feel the solution move into the tissues. It might take a couple of shots to become an expert at it, but it works. We do lots of funny thing in Australia Best wishes from Melbourne - Garry J Nervo From: Kachman Sent: Thursday, April 05, 2001 21 21 The technique described sounds like a crestal bone injection to me.... it relies on penetrating a nutrient canal n'est pas? From: Garry Nervo Sent: Friday, April 06, 2001 04 22 There have been publications (?Walton) showing that with periodontal ligament injection techniques the solution actually significantly passes through the inter radicular bone, it is cancellous and porous. I suspect the route is similar with the A-S technique. - Garry Nervo The mylohyoid injection should be against the mandible in the area of the apex of the L2M (lower 2nd molar-Stropko's interplanatary classification). The foramen is named the f. coli. Y'all put that in your pipe-and-smoke-it! I routinely inject the foramen coli for all mandibular procedures and rarely have a problem. Hope this helps when you thinks you "missed the mandibular block". John Stropko From: Jerry Avillion Sent: Thursday, April 05, 2001 11:12 AM Subject:anesthesia problems There has been discussion about the X-tip and Stabident on ROOTS. Some weeks I can't miss a block, and some days I just can't hit one to save my life. Colleagues have recommended Articaine, and have even said that if you give an infiltration for a lower molar, it will get numb. REALLY?!@#? An infiltration?>> If you give a block and get lip signs but still don't have pulpal anesthesia, I've noticed that infiltrating Septocaine will 'help', sometimes. At worst, it numbs the area so you can give interosseous. Anecdotally, the younger the patient, the better it 'helps'. Have there been any complications associated with this anesthetic? There is a higher incidence of parasthesia with any 4% solution of local (Septocaine, Citanest) when giving an IAN block. It's statistically significant, but there is debate as to if it's clinically significant. Personally, I don't use 4% solutions of local for mandibular blocks. Jerry Avillion Jerry, You mentioned the situation where the patient has lip sign (clinical anesthesia) but not pulpal anesthesia. Usually, this is an indication that there is accessory innervation, either from the mylohyoid nerve or the deep cervical nerve. Restorative dentists usually will encounter this when preparing a tooth for a crown and when they come to either the ML or MB line angle the patient feels profound pain. In this situation, even if you were to "sweet-talk" the patient into a pulp exposure, the intrapulpal will not be effective because the accessory innervation supplying this tooth has not been anesthetized. The mylohyoid injection is given in the floor of the mouth against the body of the mandible and the deep cervical is given over the external oblique ridge, like if one is giving a long buccal, but the needle is advanced toward the angle of the mandible. For what its worth. Respectfully, Blake McKinley, Jr., DDS Endodontics Exclusively From: M. L. Walker Sent: Friday, April 06, 2001 09 17 One thing you might try is using a 25 ga. needle if you aren't already. Also, there will be a hands-on anesthesia course in Seattle in early October. Taught by a gum cutter from Arizona.:-) You should be able to sign up for the course in late July or August. I'll post the pertinent information when it becomes available. Lynn Walker Tacoma, WA USAB Group Member From: John J. Stropko, D.D.S. Sent: Sunday, April 08, 2001 01 33 The mylohyoid injection should be against the mandible in the area of the apex of the L2M (lower 2nd molar-Stropko's interplanatary classification). The foramen is named the f. coli. Y'all put that in your pipe-and-smoke-it! I routinely inject the foramen coli for all mandibular procedures and rarely have a problem. Hope this helps when you think you "missed the mandibular block". - John Stropko From: I. Blake McKinley, Jr. Sent: Monday, April 09, 2001 21 54 John, Thanks for the clarification. You stated, the mylohyoid injection is given in the area of the apex the mandibular second molar. I will typically give this injection at the apex of the molar I am treating. Usually, this is apical to the lingual attached gingiva and into the lingual unattached gingiva of the floor of the mouth. The anesthetic is always delivered against the body of the mandible. - Blake Jr From: "Dr. Debra" Sent: Friday, April 13, 2001 8:17 AM I would like to more about the A-S technique you mentioned, Dr. Nervo. Are there any other sites you may want to recommend? Dr. Debbie Occena Davao City, Philippines From: "Molar Del Sud (Ace Dentura)" Sent: Friday, April 13, 2001 10:07 AM http://www.comfordent.com http://www.karna-ddscomfordent.com/ipa2.html
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