C119 LOCAL ANESTHETICS: DENTISTRY S MOST IMPORTANT DRUGS STANLEY MALAMED, DDS THURSDAY, FEBRUARY 20

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1 C119 LOCAL ANESTHETICS: DENTISTRY S MOST IMPORTANT DRUGS STANLEY MALAMED, DDS THURSDAY, FEBRUARY 20 DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission has been granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide right to distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has been granted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in any form or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Society does not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Society shall not be sued for any claim involving the distribution of this work.

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3 What s New in LOCAL ANESTHESIA Dr. Stanley F. Malamed Dentist Anesthesiologist Emeritus Professor of Dentistry Ostrow School of Dentistry of U.S.C. Los Angeles, CA, USA 1 2 What s New in Local Anesthesia Stanley F. Malamed, D.D.S Dr. Stanley F. Malamed malamed@usc.edu 2013 Dr. Stanley F. Malamed 3 4

4 I am a paid consultant to: Septodont, Inc. Onpharma DISCLOSURE What s New in Local Anesthesia (1) What s Available (2) What s New: Nasal mist for maxillary anesthesia Buffered local anesthetic Reversing local anesthesia C-CLAD Articaine & mandibular infiltration in adults 2013 Dr. Stanley F. Malamed 5 6 Our most common fears PAIN Public speaking Going to the dentist Heights Mice Flying Other/no fears The DENTIST The greatest fear dental patients have is FEAR of PAIN 7 8

5 Local anesthetics Articaine Worldwide Yet, LOCAL ANESTHETICS are the SAFEST and MOST EFFECTIVE drugs in medicine for the PREVENTION & MANAGEMENT of pain Bupivacaine Lidocaine Mepivacaine Prilocaine 9 10 Deposit a Local Anesthetic Close to a Nerve and It WILL Produce Pain Control ESTERS 1885 to late 1940 s Cocaine Procaine Tetracaine Benzocaine Chloroprocaine Propoxycaine 11 12

6 AMIDES BUPIVACAINE HCL ETIDOCAINE HCl LIDOCAINE HCL MEPIVACAINE HCL PRILOCAINE HCL 1976 (2000 USA) Articaine Local Anesthetic Clinical Duration Based on expected clinical duration of pulpal anesthesia: Procaine Cocaine Tetracaine Hybrid Normal Distribution Curve Short-acting = ~30 minutes Lidocaine Prilocaine Mepivacaine Articaine Intermediate-acting = ~60 minutes Long-acting = 90 minutes or greater 2013 Dr. Stanley F. Malamed 15 16

7 All injectable local anesthetics are VASODILATORS Cocaine Blood flow through area is INCREASED Short - duration LAs - USA Drug Onset (textbook) Pulpal Soft Tissue Mepivacaine 3% 3-5 min min Infiltration - Nerve 2-3 hours block LA diffuses OUT of AREA more rapidly Prilocaine 4% 3-5 min min Infiltration - Nerve 2-4 hours block PLAIN LAs provide a SHORT-DURATION of NOT AS PROFOUND anesthesia To increase DURATION, and to increase DEPTH, of anesthesia, a VASOCONSTRICTOR is added to the LA solution USA Epinephrine Levonordefrin Worldwide Epinephrine Norepinephrine Felypressin 19 20

8 Intermediate - duration LAs - USA Articaine 4% Lidocaine 2% Drug Onset (textbook) Pulpal Soft Tissue Epi 1:100k 1:200k Epi 1:50k, 1:100k 2-3 min 60 min 3-5 hours 3-5 min 60 min 3-5 hours Through addition of a vasoconstrictor, the ensuing BLOOD LEVEL of the local anesthetic is significantly decreased, thereby minimizing risk of overdose (toxic reaction) Mepivacaine 2% Prilocaine 4% Levonordefrin 1:20k Epi 1:200k 3-5 min 60 min 3-5 hours 3-5 min 60 min 3-8 hours Epinephrine Levonordefrin Epi = Epinephrine (Adrenalin) Anesthetic blood levels Long - duration LAs - USA Injection site Anesthetic Dose (mg) Epinephrine dilution Peak blood level Infiltration Mepivacaine 5 mg/kg None min Drug Onset (textbook) Pulpal Soft Tissue Infiltration Mepivacaine 5 mg/kg 1:200, Infiltration Lidocaine 400 None 2 20 min 10 min Bupivacaine 0.5% Epi 1:200k 6-10 min min (up to 7 hours) up to 12 hours Infiltration Lidocaine 400 1:200, min 23 24

9 Maximum recommended therapeutic dosages Drug Mg/kg Absolute maximum Articaine HCl 7 n/a Bupivacaine HCl *** 90 Lidocaine HCl Whats s New in Local Anesthesia Mepivacaine HCl Prilocaine HCl Intranasal Local Anesthetic Mist Maxillary anesthesia without injection The LA ON switch The LA OFF switch C-CLAD Articaine - mandibular infiltration 27 Intranasal Local Anesthetic Mist 28

10 Intranasal Drug Administration Intranasal Drug Administration Illicit drugs: Cocaine Intranasal Drug Administration Intranasal Drug Administration Emergency medicine Pediatric grand mal status... Midazolam Pediatric sedation (dentistry)... Midazolam 31 32

11 Intranasal Drug Administration Intranasal Sedation (Midazolam) Primarily YOUNGER pediatric patients Common in management of STATUS EPILEPTICUS in children 1993 SEDATION 0.2 mg/kg Intranasal Drug Administration As rapid onset as IM no needle stick Equal potency to IM Equal duration to IM May cause burning sensation Disagreeable taste Atomizer used Above may increase patients combativeness Intranasal Local Anesthesia MAD Intranasal Atomizer Device 2013 Dr. Dr. Stanley F. F. Malamed All 35 36

12 Maxillary anesthesia without injection Phase 2 clinical trial: 2009 Dr Sebastian Ciancio, SUNY Buffalo Nasal spray of local anesthetic provides pulpal anesthesia to maxillary anterior teeth NEWS RELEASE Nasal Spray May End Dental Needle Injections for Upper Teeth Repair Release Date: February 17, 2009 BUFFALO, N.Y. -- A nasal spray shown to numb the upper jaw is set to Contact be tested in an FDA Phase 3 trial, which will assess the spray's Lois Baker ljbaker@buffalo.edu effectiveness compared to the current "gold standard" treatment ext 1417 painful anesthesia injections. "A successful trial of this new dental anesthetic will change dental technology worldwide," said Sebastian Ciancio, D.D.S., University at Buffalo SUNY Distinguished Service Professor and chair of the Department of Periodontics and Endodontics. Ciancio directed the Phase 2 trial and will coordinate the Phase 3 trial. Between 6 and10 million dental needle injections are given daily, according to Ciancio. Results of the FDA Phase 2 trial, conducted in 48 subjects at the UB School of Dental Medicine, showed that the spray appears to be safe and effective. The Phase 3 trial will be carried out later in 2009 at the UB dental school and other clinical sites. Ciancio said that if the Phase 3 trial is successful, it may mean the end of injections for any dental work performed on the upper teeth. Ciancio and colleagues conducted the initial preliminary dental studies using the nasal spray, which is being developed by St. Renatus, LLC, based in Fort Collins, Colo. 37 Intranasal Local Anesthetic Mist By mid - to late (hopefully) we will be able to administer a local anesthetic intranasally to provide profound pulpal anesthesia from # 4 to # Intranasal Local Anesthetic Mist Intranasal Local Anesthetic Mist 3% Tetracaine Ester-type local anesthetic Commonly used by ENT surgeons Has track record as safe & effective IN Vasoconstrictor Oxymetazoline Active ingredient in Afrin & other nasal decongestants 39 40

13 JADA 143(8): , Intranasal Local Anesthetic Mist Phase 2 clinical trial 3% Tetracaine Oxymetazoline (active ingredient in Afrin nasal spray) Sprayed into R & L nares JADA 143(8): , N =

14 Phase 2 clinical trial N = 48 Injectable (lidocaine + epi) 94% success 1st molar to 1st molar Phase 2 clinical trial N = 48 Nasal Mist 84% success 1st molar to 1st molar 100% success Premolar to premolar 16% failure on 1st molar Palate How long does it REALLY take for pulpal anesthesia to develop? When do we expect LAs to start working? 3-5 minute average for infiltration 5-7 minute average for nerve block Where do these numbers come from? 47 48

15 Intermediate - duration LAs - USA Articaine 4% Drug Onset (textbook) Pulpal Soft Tissue Epi 1:100k 1:200k 2-3 min 60 min 3-5 hours 95% of patients will (eventually) get numb if given a 45-minute waiting period Six-Hour Time Course for Pulpal Analgesia (EPT) IANB Second Premolar The other 5% are anatomical misses Lidocaine 2% Epi 1:50k, 1:100k 3-5 min 60 min 3-5 hours Mepivacaine 2% Levonordefrin 1:20k 3-5 min 60 min 3-5 hours Prilocaine 4% Epi 1:200k 3-5 min 60 min 3-8 hours Epi = Epinephrine (Adrenalin) Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer) Lai, et al, OOOOE, Vol 102, No 4, P (2006) 100%# 90%# 80%# 70%# 60%# 50%# 40%# 30%# 20%# 85 % Discomfort or Procedural Pain 70 % 40 % 25 % Lidocaine#IANB#Mean# Lai,#et#al,#so>#?ssue#v.#EPT# Soft tissue anesthesia is NOT a guaranteed sign of pulpal anesthesia 10%# 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# 51 52

16 100%# 90%# 80%# 70%# 60%# 50%# 40%# 30%# 20%# 10%# 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# #Kanaa#(2006)(m)(L)# #Nist#(1992)(m)(L)# #Chaney#(1991)(m)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(m)(L)# #Childers#(1996)(m)(L)# #Dagher#(1997)(m)(L)# #Goldberg#(2008)(m)(L)# #Goodman#(2006)(m)(L)# #Hannan#(1999)(1m)(L)# #Hannan#(1999)(2m)(L)# #Steinkruger#(2006)(m)(L)# #Willet#(2008)(m)(L)# #Vreeland#(1989)(m)(L)# #Kanaa#(2006)(p)(L)# #Chaney#(1991)(p)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(p)(L)# #Dagher#(1997)(p)(L)# #Goldberg#(2008)(p)(L)# #Goodman#(2006)(p)(L)# #Hannan#(1999)(p)(L)# #Willet#(2008)(p)(L)# 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Data from 28 PRP Studies Subjects ( ) 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Average for 28 PRP Studies Subjects ( ) with Lidocaine IANB Mean 100%# #Kanaa#(2006)(m)(L)# 100%# 90%# 80%# 70%# 60%# #Nist#(1992)(m)(L)# #Chaney#(1991)(m)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(m)(L)# #Childers#(1996)(m)(L)# #Dagher#(1997)(m)(L)# #Goldberg#(2008)(m)(L)# #Goodman#(2006)(m)(L)# #Hannan#(1999)(1m)(L)# #Hannan#(1999)(2m)(L)# #Steinkruger#(2006)(m)(L)# N = %# 80%# 70%# 60%# The knee in the curve is at about 10 minutes (60%) #Willet#(2008)(m)(L)# 50%# #Vreeland#(1989)(m)(L)# 50%# Lidocaine#IANB#Mean# #Kanaa#(2006)(p)(L)# #Chaney#(1991)(p)(L)# 40%# #Hinckley#(1991)(m)(L)# 40%# #McLean#(1993)(p)(L)# 30%# #Dagher#(1997)(p)(L)# #Goldberg#(2008)(p)(L)# 30%# #Goodman#(2006)(p)(L)# 20%# #Hannan#(1999)(p)(L)# 20%# #Willet#(2008)(p)(L)# #Mikesell#(2005)(m)(L)# 10%# #Mikesell#(2005)(1p)(L)# 10%# #Mikesell#(2005)(1p)(L)# 0%# Lidocaine#IANB#Mean# 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# Why do doctors LIKE articaine? Can we speed up the onset of anesthesia... Using Articaine? Anecdotal comments from dentists: It works faster It works better I don t miss as often Hard to get numb patients are easier to numb with articaine 2013 Dr. Dr. Stanley F. F. Malamed All 55 56

17 100%# 90%# 80%# 70%# 60%# 50%# 40%# 30%# 20%# 10%# 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# #Kanaa#(2006)(m)(L)# #Nist#(1992)(m)(L)# #Chaney#(1991)(m)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(m)(L)# #Childers#(1996)(m)(L)# #Dagher#(1997)(m)(L)# #Goldberg#(2008)(m)(L)# #Goodman#(2006)(m)(L)# #Hannan#(1999)(1m)(L)# #Hannan#(1999)(2m)(L)# #Steinkruger#(2006)(m)(L)# #Willet#(2008)(m)(L)# #Vreeland#(1989)(m)(L)# #Kanaa#(2006)(p)(L)# #Chaney#(1991)(p)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(p)(L)# #Dagher#(1997)(p)(L)# #Goldberg#(2008)(p)(L)# #Goodman#(2006)(p)(L)# #Hannan#(1999)(p)(L)# #Willet#(2008)(p)(L)# 30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine 100%# 90%# 80%# Ar/caine#IANB#Mean# 70%# N = 222 Articaine Lidocaine N = %# 50%# 40%# 30%# 20%# 10%# Lidocaine#IANB#Mean# Can we speed up the onset of anesthesia... By buffering the LA solution? 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# %# 30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine Buffered Lidocaine 67% N = 18 90%# 80%# 70%# 60%# 50%# Ar/caine#IANB#Mean# Lidocaine#IANB#Mean# The local anesthetic ON SWITCH 40%# 30%# Buffered Local Anesthetics 20%# #Buffered#Lido#IANB# 10%# 0%# 0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30# 59 60

18 What IS buffering? % Un-ionized (RN) LA The addition of a chemical agent to a solution which increases its ph (towards the body s normal ph of 7.4 [ ]) NaBicarbonate The body will SLOWLY buffer the anesthetic solution to a ph of 7.4 ph 7.4 (body ph) 3.5 (with epi) Lidocaine pka minutes? % Un-ionized (RN) LA ph Lidocaine pka 7.9 Articaine pka 7.8 Mepivacaine Bupivacaine pka 7.6 pka x increase in RN 7.4 (body ph) 6.5 (plain) 3.5 (with epi) :37 1:

19 Buffered Local Anesthetics Buffered Local Anesthetics It is important to note that buffering MUST occur within a very short time prior to administration of the injection - minutes before injection Why? When bicarbonate is added to Lidocaine HCl one of the products formed is carbon dioxide (CO2) CO2 has anesthetic properties, increasing the comfort of the injection as the needle advances through soft tissue Allows CO2 to Escape Medical use of Local Anesthetic Buffering So, What has happened to make LA buffering a reality in dentistry? Adsorbs active anesthetic Stabilization of the Sodium Bicarbonate Solution Dermatology Plastics & Reconstructive Surgery Allergists Draws CO2 out of solution 67 68

20 ph = 7.35 ph = 7.35 BUFFERING with Sodium Bicarbonate 69 Buffering Lidocaine HCl Lidocaine 2% + epinephrine 1:100,000 = ph 3.5 BUFFERED Lidocaine 1.75% + epi 1:125,000 + CO2 + NaHCO3 = ph 7.4 More dilute 6,000 x more active ions to enter nerve 70 Clinical Data Pain Free Injections Summary Clinical Trial Data 44% of buffered anesthetic patients experienced zero injection pain 6% of traditional anesthetic patients experienced zero injection pain 50% 38% 25% 13% 6% 44% 0% Control Buffered Malamed SF, Hersh E, Poorsattar S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11, Malamed SF, Hersh E, Poorsattar S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11,

21 Clinical Data Patient Preference Clinical Data Onset less than 2 minutes 80%$ 71%$ 70%$ 80% 72% 60%$ 60% 50%$ 72 % of patients rated buffered anesthetic as the more comfortable injection 40% 20% 17% 11% 40%$ 30%$ 20%$ 10%$ 12%$ 0% No Difference Buffered Control 0%$ Lidocaine$w/$Epi$ Buffered$Lidocaine$w/$Epi$ Malamed SF, Hersh E, Poorsattar S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11, Malamed SF, Hersh E, Poorsattar What%Percentage%of%Par.cipants%Achived%Pulpal% S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine Anesthesia%in%Under%2%Minutes?% 1:100,000. Compendium 34:(spec issue #1):1-11, Buffered Local Anesthetics When buffering is done properly the following advantages can be expected from the increase in ph: 1. More comfortable injection 2. Faster onset of anesthesia 3. More profound anesthesia 4. Less post-injection soreness Increased depth of anesthesia Theoretically: With more RN entering into nerve (~6000x) buffered LA should provide INCREASED DEPTH of anesthesia Phase 3 clinical trials ONGOING at this time Anecdotal evidence (endodontists) = It works 75 76

22 Duration of Anesthesia Safety in Pediatrics When buffering is done properly: No evidence of any effect on DURATION NO elevation in LA blood levels Why is buffering doing well? The doctor SEES the benefit (1) More comfortable injection for patient ph of anesthetic 7.35 to 7.5 (2) More rapid onset on pulpal anesthesia (3) More profound anesthesia (4) No effect on duration of action The local anesthetic ON SWITCH Buffered Local Anesthetics 79 80

23 The local anesthetic OFF SWITCH Phentolamine Mesylate PLAIN LAs provide a SHORT-DURATION of NOT VERY PROFOUND anesthesia To increase DURATION, and to increase DEPTH, of anesthesia, a VASOCONSTRICTOR is added to the LA solution More (LA) drug enters the nerve, it remains IN the nerve longer in a higher concentration, increasing BOTH the duration & depth of anesthesia Epinephrine Levonordefrin Epinephrine Levonordefrin 83 84

24 Soft tissue anesthesia ALWAYS begins first followed, hopefully, by pulpal Pulpal anesthesia is lost first followed, usually hours later, by soft tissue Pulpal analgesia level Pulpal analgesia level Soft tissue analgesia level Soft tissue analgesia level Intermediate - duration LAs - USA Articaine 4% Lidocaine 2% Mepivacaine 2% Prilocaine 4% Drug Onset - textbook Pulpal Soft Tissue Epi 1:100k 1:200k Epi 1:50k, 1:100k Levonordefrin 1:20k Epi 1:200k 2-3 min 60 min 3-5 hours 3-5 min 60 min 3-5 hours 3-5 min 60 min 3-5 hours 3-5 min 60 min 3-8 hours The PROBLEM, on occasion, is RESIDUAL SOFT TISSUE ANESTHESIA Epi = Epinephrine (Adrenalin) 87 88

25 Patients feel that residual STA interferes with their normal daily activities in three areas: 13% of pediatric patients receiving IANB suffer post-treatment traumatic injury to soft tissues. Perceptual (perception of altered physical appearance), Functional (diminished ability to speak, smile, drink, and control drooling), Sensory (lack of sensation) Age % with soft tissue trauma < 4 years 18% 4-7 years 16% 8-11 years 13% 12+ 7% Rafique S, Fiske J, Banerjee A. Clinical trial of an air-abrasion/chemomechanical operative procedure for restorative treatment of dental patients. Caries Res 37: , 2003 College C, Feigal R, Wandera A, Strange M. Bilateral versus unilateral mandibular block anesthesia in a pediatric population. Pediatr Dent. 22(6): , Phentolamine mesylate is a vasodilator (an alpha adrenergic antagonist) that increases vascular perfusion in the area of injection. Phentolamine Mesylate Pediatric Dentistry Epinephrine constricts blood vessel Phentolamine dilates blood bessel This increased perfusion leads to an increased rate of the LA diffusing out of the nerve into the cardiovascular system, thereby decreasing the duration of residual soft tissue anesthesia. Blood levels of local anesthetics: Drug leaves nerve more rapidly Blood level should be increased Is there an increased risk of overdose? 91 92

26 Phentolamine Mesylate Pediatric Dentistry Rutherford B, Zeller JR, Thake D. Local and Systemic Toxicity of Intraoral Submucosal Injections of Phentolamine Mesylate (OraVerse). Anesthesia Progress: 56(4) , 2009 Moore PA, Hersh EV, Papas AS, Goodson JM, Yagiela JA, Rutherford B, Rogy S, Navalta L. Pharmacokinetics of Lidocaine With Epinephrine Following Local Anesthesia Reversal With Phentolamine Mesylate. Anesthesia Progress: 55(2) 40-48, Local Anesthesia Reversal YES YES Does it work? 95 96

27 Percep=on of normal appearance and func=on Accelerated by 60 min. 1 Control PM Accelerated by: UPPER LIP 133 minutes 50 minutes 83 minutes Restora=on of normal sensa=on of tongue Accelerated by 65 min. administer LA + epi Phentolamine Mesylate Effect on soft tissue anesthesia end of traumatic dental procedure dinner LA + epi Restora=on of normal func=on Accelerated by 60 min. Control PM Accelerated by: Thanks to: Suzete Brasil, Erica Dicterow, Fariba Neumann & Joan Ong LOWER LIP 155 minutes 70 minutes 85 minutes LA + epi + PM PM Pulpal Soft tissue Phentolamine mesylate is administered in a 1:1 ratio with the number to LA cartridges previously given Phentolamine Mesylate OraVerse Conservative dental treatment Non-surgical periodontics (SRP) Pediatric dentistry Medically compromised patients: e.g.: Diabetics Geriatric patients Special needs patients Post mandibular implants

28 Phentolamine Mesylate OraVerse NOT suggested for: Post-surgery Bupivacaine HCl + NSAID are indicated Following PDL (ILI) or Intraosseous (IO) Computer-Controlled Local Anesthetic Delivery The local anesthetic needle & syringe are the most fear-inducing items in the dental armamentarium ELECTRONIC DENTAL ANESTHESIA 1980 s We have tried - over many years - to eliminate the needle and / or syringe

29 PERIODONTAL LIGAMENT INJECTION 1980 s INTRAOSSEOUS ANESTHESIA 1990 s Stabident X-Tip

30 STA - Single Tooth Anesthesia System Computer-Controlled Local Anesthetic Delivery Popular in Europe & Asia Ability to administer ANY injection virtually PAINLESSLY ARTICAINE Mandibular Infiltration in Adolescent & Adult Patients Articaine HCl by Mandibular Infiltration in Adults Mandibular infiltration John Meechan (UK) Al Reader (USA)

31 Pulp test every 2 min SUCCESS = 80/80 on 2 consecutive tests Pulp test every 3 min SUCCESS = 80/80 on 2 consecutive tests Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 IANB s at each of 2 visits = 2% lidocaine + epi 1:80K One visit = 4% articaine + epi 1:100K infiltration buccal fold 1st molar (2.0 ml) 1st molar Lidocaine IANB One visit = dummy injection buccal fold 1st molar Pulp test for 45 minutes Lidocaine IANB + dummy % 1st molar Significant, p<

32 Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , st molar Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , st Molar Lidocaine IANB followed by Articaine buccal infiltration (by molars) Lidocaine IANB + Articaine % Significant, p< st molar Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , st premolar 1st premolar Lidocaine IANB Lidocaine IANB + dummy % 1st premolar p<0.021 Lidocaine IANB followed by Articaine buccal infiltration (by molars) Lidocaine IANB + Articaine % 1st premolar p<

33 Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , st Premolar Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Lateral incisor Lidocaine IANB Lidocaine IANB + dummy % Lateral incisor Significant, p< Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Lateral incisor Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Lateral Incisor Lidocaine IANB followed by Articaine buccal infiltration (by molars) Lidocaine IANB + Articaine % Lateral incisor Significant, p<

34 Anesthesia success 2+ consecutive 80/80 readings IA + a-caine infiltration Failure n (%) IA + a-caine infiltration Success n (%) IA + dummy infiltration Failure n (%) IA + dummy infiltration Success n (%) McNemar Test P-value 1st molar 3 (8.3) 33 (91.7) 16 (44.4) 20 (55.6) <0.001 Premolars 4 (11.1) 32 (88.9) 12 (33.3) 24 (66.7) Lateral incisors 8 (22.2) 28 (77.8) 29 (80.6) 7 (19.4) <0.001 Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42: , 2009 Clinical trial protocol required articaine to be infiltrated in buccal fold adjacent to the 1st mandibular molar Rational use: Articaine infiltration in buccal fold adjacent to tooth being treated Meechan & Ledvinka Mandibular incisors ARTICAINE HCl 1.0 ml Articaine 1:100k BUCCAL lateral incisor: Central incisor: 94% 1.0 ml Articaine 1:100k BUCCAL & LINGUAL lateral incisor: Central incisor: 97% Mandibular incisors Articaine B&L Articaine B Lidocaine B&L Lidocaine B Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35: ,

35 What s New in Local Anesthesia (1) What s Available (2) What s New: Nasal mist for maxillary anesthesia Buffered local anesthetic Reversing local anesthesia C-CLAD Articaine & mandibular infiltration in adults Dr. Stanley F. Malamed OR Dr. Stanley F. Malamed What s New in LOCAL ANESTHESIA 131