LOCAL ANESTHESIA Update

© 2015 Dr. Stanley F. MalamedAll Rights Reserved

LOCAL ANESTHESIA Update

Stanley F. Malamed, DDS Dentist Anesthesiologist

Emeritus Professor of Dentistry Ostrow School of Dentistry of USC

Los Angeles, California, USA

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I have a relationship with the following companies that may be relevant to this presentation. I am a paid consultant to:


Septodont, Inc OnPharma St. Renatus 3M ESPE

Stanley F. MALAMED, DDS Dentist Anesthesiologist


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LOCAL ANESTHETICS are the SAFEST and MOST EFFECTIVE

drugs in medicine for the PREVENTION & MANAGEMENT of pain

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Local Anesthetic Use in Dentistry

Annual LA usage (approximate)

300 x 106 USA (300,000,000) 80 x 106 Germany

40 x 106 U.K. Amides have been available since 1948


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Esters

Amides

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Lidocaine

1st AMIDE local anesthetic Introduced 1948

Astra Pharmaceuticals (SWEDEN)

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Lidocainewith

epinephrine 1: 50,000* 1: 80,000

1:100,000* 1:200,000 1:300,000

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• Duration of pulpal anesthesia = ~60 minutes

• Duration of soft tissue anesthesia = ~3 - 5 hours

Lidocaine 2% with vasoconstrictor


Intermediate - Duration LA

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• Indicated for:• Dental therapy of approximately 45 - 60 minute duration

• Depth of pulpal anesthesia usually adequate for pulpally-involved teeth

• Pediatric patients (< 30 kg) when treating one or more quadrants

Lidocaine 2% with vasoconstrictor


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Mepivacaine

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Mepivacaine3%

No vasoconstrictor

Mepivacaine2%

With vasoconstrictor

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• Duration of pulpal anesthesia (infiltration) = ~20 minutes

• Duration of pulpal anesthesia (nerve block) = ~40 minutes


Mepivacaine 3% No vasoconstrictor


Short - Duration LA

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• Indicated for:• Dental therapy of SHORT duration (~30 minutes)

• Depth of pulpal anesthesia MAY NOT be adequate for pulpally-involved teeth

• Pediatric patients (< 30 kg) when treating one quadrant only

Mepivacaine 3% No vasoconstrictor


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Mepivacainewith

epinephrine (Canada)

1:100,000

with levonordefrin (USA)

1: 20,000

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Mepivacaine 2% with vasoconstrictor



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Mepivacaine 2% with vasoconstrictor

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Prilocaine

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Prilocaine4%

No vasoconstrictor

Prilocaine3% or 4%

With vasoconstrictor

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• Duration of pulpal anesthesia (infiltration) = ~20 minutes

• Duration of pulpal anesthesia (nerve block) = ~40 - 60 minutes


Prilocaine 4% No vasoconstrictor


Short - Duration LA

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• Indicated for:• Dental therapy of SHORT duration (~30 minutes)


• Pediatric patients (< 30 kg) when treating one quadrant only



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• Not indicated for:• Appears to be associated with a higher risk of

paresthesia following IANB (see Pogrel 2007, 2012 JCDA)


• Pediatric patients (< 30 kg) when treating more than one quadrant



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Prilocaine4% with

epinephrine1:200,000

3% with feltpressin

0.3 IU

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Prilocaine 3% or 4% with vasoconstrictor



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• Not indicated for:• Appears to be associated with a higher risk of

paresthesia following IANB (see Pogrel 2007, 2012 JCDA)



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Bupivacaine

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Bupivacaine0.5% with

epinephrine1:200,000

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• Duration of pulpal anesthesia = >90 minutes (nerve block)


Bupivacaine 0.5% with vasoconstrictor


Long - Duration LA

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• Indicated for:• Dental therapy of > 2 hour duration

• Post-surgical pain control


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• Not indicated for:• Rarely indicated for administration to children (long

duration soft tissue anesthesia = increased risk of self-inflicted soft tissue injury)



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Articaine

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Articaine4% with

epinephrine1:100,000 1:200,000

• Synthesized in Germany 1973 • Introduced Germany 1976 • Canada 1985

1st & only Local anesthetic designed for dentistry

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• Duration of pulpal anesthesia (infiltration) = 60 minutes

• Duration of pulpal anesthesia (nerve block) = 60 minutes

• Duration of soft tissue anesthesia = 3 - 5 hours

Articaine 4% Epinephrine 1:100,000 & 200,000

100,000 200,000


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• Indicated for:• Dental therapy of approximately 60 minute duration




100,000 200,000 © 2015 Dr. Stanley F. MalamedAll Rights Reserved

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• Indicated for:• Pregnant patients*

• Nursing mothers*

• Mandibular infiltration in adult patients*


100,000


200,000

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• Indicated for:• Hemostasis

• 1:100,000 provides better hemostasis than 1:200,000

Articaine 4% Epinephrine 1:100,000

100,000


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• Should I use articaine 4% with 1:100,000 or 1:200,000 epineprine?

• Though BOTH epinephrine concentrations are SAFE in most patients, the lesser concentration (1:200,000) is preferred as there is NO clinical difference in either the DEPTH or DURATION of PAIN CONTROL.


100,000

200,000


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• Should I use articaine 4% with 1:100,000 or 1:200,000 epineprine?


100,000


• For HEMOSTASIS during surgical procedures, small volumes of 1:100,000 epinephrine infiltrated is recommended.

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Local Anesthetics by EXPECTED duration of PULPAL anesthesia


NormalDistribution

Curve

Bell-ShapedCurve

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Local Anesthetics by EXPECTED duration of PULPAL anesthesia

• Short-duration (~30 minutes)

• Mepivacaine 3%, Prilocaine 4%

• Intermediate-duration (~60 minutes)

• Articaine 4%, Lidocaine 2%, Mepivacaine 2%, Prilocaine 4% (all with vasoconstrictor)

• Long-duration (>90 minutes)

• Bupivacaine 0.5% (with vasoconstrictor) © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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Maximum recommended therapeutic dosages

Drug Mg/kg Absolute maximum

Articaine HCl 7 n/a

Bupivacaine HCl *** 90

Lidocaine HCl 7 500

Mepivacaine HCl 6.6 400

Prilocaine HCl 8 600 © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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Whats’s Newin

Local Anesthesia?

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Articaine - mandibular infiltration The LA ‘OFF’ switch The LA ‘ON’ switch Maxillary anesthesia without injection


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Articaine HCl by Mandibular Infiltration in Adults

Mandibular infiltration

John Meechan (UK)Al Reader (USA)


ARTICAINE HCl

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IA + a-caine infiltration

IA + a-caine infiltration

IA + dummy infiltration

IA + dummy infiltration

Anesthesia success >2 consecutive 80/80 readings

Failuren (%)

Successn (%)

Failuren (%)

Successn (%)

McNemar TestP-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) 0.021

Lateral incisors

8 (22.2) 28 (77.8) 29 (80.6) 7 (19.4) <0.001


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Kanaa JM, Whitworth JM, Corbett IP, Meechan JGArticaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block.Int Endodont J 42:238-246, 2009

1st Molar91.7%

55.6%

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1st Premolar88.9%

66.7%

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Lateral Incisor

77.8%

19.4%

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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL infiltration @ lateral incisor:

Central incisor: 94%

Mandibular incisorsARTICAINE HCl

Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002

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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL & LINGUAL infiltration @ lateral incisor:


Mandibular incisorsARTICAINE HCl


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Mandibular incisors

Articaine B&L

Articaine B

Lidocaine B&L

Lidocaine B


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Phentolamine Mesylate

The local anesthetic “OFF SWITCH”

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PLAIN LAs provide a

SHORT-DURATION of

NOT VERY PROFOUND anesthesia


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To increase DURATION, and to increase DEPTH, of anesthesia, a VASOCONSTRICTOR is added to the LA solution

EpinephrineLevonordefrin


FelypressinNorepinephrine

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Intermediate - duration LAs - USA

Articaine 4%Epi

1:100k1:200k 2 - 3 min 60 min 3 - 5 hours

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

Drug Onset (textbook) Pulpal Soft Tissue

Epi = Epinephrine (Adrenalin) © 2015 Dr. Stanley F. MalamedAll Rights Reserved

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The PROBLEM, on occasion,

is RESIDUAL SOFT TISSUE ANESTHESIA


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Age % with soft tissue

trauma< 4 years 18%4 - 7

years16%

8 - 11 years

13%12+ 7%

13% of pediatric patients receiving IANB suffer post-treatment traumatic injury to soft tissues.


College C, Feigal R, Wandera A, Strange M. Bilateral versus unilateral mandibular block anesthesia in a pediatric population. Pediatr Dent. 22(6):453-457, 2000.

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Phentolamine Mesylate

The local anesthetic “OFF SWITCH”

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Phentolamine mesylate is a vasodilator (an alpha adrenergic antagonist) that increases vascular perfusion in the area of injection.

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.

Epinephrineconstricts blood vessel

Phentolamine dilates blood vessel


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Local Anesthesia Reversal

Does it work?60


YES! YES!

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1

1

UPPER&LIP

Control 133&minutesPM 50&minutes

Accelerated&by: 83&minutes

&&LOWER&LIP

Control 155&minutesPM 70&minutes

Accelerated&by: 85&minutes

Percep&on)of)normal)appearance)and)func&on)Accelerated&by&60&min.

Restora&on)of)normal)func&on)

Accelerated&by&60&min.

3

Restora&on)of)normal)sensa&on)of)tongue)

Accelerated&by&65&min.

4

Thanks to: Suzete Brasil, Erica Dicterow, Fariba Neumann & Joan Ong © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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Conservative dental treatment Non-surgical periodontics (SRP)

Pediatric dentistry Medically compromised patients:

e.g.: Diabetics Geriatric patients Special needs patients Post-mandibular implants

Phentolamine MesylateOraVerse


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Buffered Local Anesthetics Alkalinized Local Anesthetics

The local anesthetic “ON SWITCH”

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How long does it take for pulpal anesthesia to develop?


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Articaine 4%Epi

1:100k1:200k 2 - 3 min 60 min 3 - 5 hours

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

Drug Onset (textbook) Pulpal Soft Tissue

Epi = Epinephrine (Adrenalin)

Intermediate - duration LAs - USA


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How long does it REALLY take for pulpal anesthesia to develop?


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30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#

Lidocaine#IANB#Mean#

Lai,#et#al,#so>#?ssue#v.#EPT#

70%

25%


At 4 minutes: 70% soft tissue numb 25% pulpal anesthesia

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Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#



85%

40%


30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)

At 6 minutes: 85% soft tissue numb 40% pulpal anesthesia

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0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#



Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006)


OW!

30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer)

70%

25%

85%

40%

70

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#


30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsAverage for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean

N = 1078


Most doctors wait ~10 minutes

At 10 minutes: 60% pulpal anesthesia

71

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#


Many practitioners wait 15 minutes (67%)

N = 1078


30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsAverage for 28 PRP Studies - 1078 Subjects (1991 - 2008) with Lidocaine IANB Mean

Some doctors wait ~15 minutes

At 15 minutes: 67% pulpal anesthesia

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IANB: Lidocaine + epinephrine

% clinically effective pulpal anesthesia

• 25% at 4 minutes




• 95% at 45 minutes © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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Can we speed the onset of anesthesia . . .

0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

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)#


#McLean#(1993)(p)(L)#

#Dagher#(1997)(p)(L)#

#Goldberg#(2008)(p)(L)#

#Goodman#(2006)(p)(L)#

#Hannan#(1999)(p)(L)#

#Willet#(2008)(p)(L)#

with Articaine? © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#

Ar/caine#IANB#Mean#


30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine

Articaine

Lidocaine

N = 222

N = 1078


ARTICAINE + epinephrine

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Can we speed the onset of anesthesia

with Articaine?

NO © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

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)#


#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)#


#McLean#(1993)(p)(L)#

#Dagher#(1997)(p)(L)#

#Goldberg#(2008)(p)(L)#

#Goodman#(2006)(p)(L)#

#Hannan#(1999)(p)(L)#

#Willet#(2008)(p)(L)#

by buffering the LA solution?


Can we speed the onset of anesthesia . . .

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© 2014 Dr. Stanley F. MalamedAll Rights Reserved © 2013 Dr. Stanley F. Malamed

All Rights Reserved


30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, ArticaineBuffered Lidocaine

67%N = 18

BUFFERED lidocaine + epinephrine


0%#

10%#

20%#

30%#

40%#

50%#

60%#

70%#

80%#

90%#

100%#

0# 2# 4# 6# 8# 10# 12# 14# 16# 18# 20# 22# 24# 26# 28# 30#

Ar/caine#IANB#Mean#


#Buffered#Lido#IANB#

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by buffering the solution?

YES © 2015 Dr. Stanley F. Malamed

All Rights Reserved

Can we speed the onset of anesthesia

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Buffered Local Anesthetics

The local anesthetic “ON SWITCH”

Alkalinized Local Anesthetics

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Buffered Lidocaine by IANB

Pain Control Options

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By INCREASING the pH of the local anesthetic solution from 3.5 to 7.35 we:

• Make the injection more comfortable• Increase the effectiveness of the LA• Dramatically decrease the onset time• Decrease postoperative ‘soreness’

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Clinical Trial DataSummary

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, 2013 © 2014 Dr. Stanley F. Malamed

All Rights Reserved

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6:37

1:51


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FDA Approved for Lidocaine HCl

Lidocaine 2% + epinephrine 1:100,000 = pH 3.5BUFFERED

Lidocaine 1.75% + epi 1:125,000 + CO2 + NaHCO3 = pH 7.4

More dilute 6,000x more active ions to enter nerve


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Onset treatment recommendations

1. Administer buffered lidocaine IANB 2. DO NOT LEAVE PATIENT !!! 3. You will know if your block is successful in 2 minutes 4. Check for pulpal anesthesia:

• EPT or Endo-Ice 5. In 2 minutes following

IANB begin tooth preparation © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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ARTICAINE


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ArticaineUltracain

Septocaine Articadent Vivacaine Septanest

Alphacaine Zorcaine

88


Articaine4% with

epinephrine1:100,000 1:200,000

• Synthesized in Germany 1973 • Introduced Germany 1976

1st & only Local anesthetic designed for dentistry

89

• Duration of pulpal anesthesia (infiltration) = 60 minutes

• Duration of pulpal anesthesia (nerve block) = 60 minutes

• Duration of soft tissue anesthesia = 3 - 5 hours



100,000 200,000

90


As sole injection by mandibular infiltration

Buccal infiltration - ARTICAINE

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Mandibular infiltrationJohn Meechan (UK)


Al Reader (USA)


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JADA 138(8):1104-1112, 2007

Articaine LidocaineMandibular 2nd Molar 75% 45%

Mandibular 1st Molar 87% 57%

Mandibular 2nd Premolar 92% 67%

Mandibular 1st Premolar 86% 61%

p value for all: >.0001

Pulp test every 3 min

SUCCESS = 80/80 on 2

consecutive tests

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Meechan & Ledvinka1.0 mL Articaine 1:100k BUCCAL infiltration @ lateral incisor:


Mandibular IncisorsARTICAINE HCl


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Meechan & Ledvinka

1.0 mL Articaine 1:100k BUCCAL & LINGUAL infiltration @ lateral incisor:


Mandibular IncisorsARTICAINE HCl


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Mandibular Incisors

Articaine B&L

Articaine B

Lidocaine B&L

Lidocaine B

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Advantages1. Profound pulpal anesthesia2. 30 to 40 minute duration of plural anesthesia3. Minimal accessory soft tissue anesthesia

• Tongue



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Disadvantage

I can’t think of any, unless it doesn’t work!



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Articaine infiltration as a supplement

to IANB


99


Kanaa JM, Whitworth JM, Corbett IP, Meechan JGArticaine buccal infiltration enhances the effectiveness

of lidocaine inferior alveolar nerve block.Int Endodont J 42:238-246, 2009

100


1st Molar91.7%

55.6%

Articaine infiltration as a supplement to IANB

101


1st Premolar88.9%

66.7%


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Lateral Incisor

77.8%

19.4%


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Intranasal Local Anesthesiain the Maxilla

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Intranasal Local Anesthetic Mist

Intranasal Local Anesthetic Mist © 2015 Dr. Stanley F. MalamedAll Rights Reserved

105

In mid-2015 in the USAwe will be able to administer

a local anesthetic intranasally to provide profound pulpal anesthesia

from #1.1 to 1.5 and 2.1 to 2.5(#4 to #13)



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3% TetracaineEster-type local anestheticCommonly used by ENT surgeonsHas ‘track record’ as safe & effective IN



107




OxymetazolineVasoconstrictorActive ingredient in ‘Afrin’ & other nasal decongestants



108

3% TetracaineOxymetazoline

(active ingredient in Afrin nasal spray)

Sprayed into R & L naresN = 48


Phase 2 clinical trial


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Injectable (lidocaine + epi)

94% success1st molar to 1st molar


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Palate

84% success 1st molar to 1st molar

100% successPremolar to premolar

Nasal Mist

16% failure on 1st molar © 2015 Dr. Stanley F. Malamed

All Rights Reserved

111




JADA 143(8):872-880, 2012


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Whats’s Newin

Local AnesthesiaIn the more distant future

113



Optical control of pain-sensing neurons. QAQ selectively enters pain sensing neurons and

silences their activity (top, green light). Illumination with violet light (bottom) quickly restores signal

conduction


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Very Long-Acting

Analgesia

2014 DRUGS


115



2014 DRUGS

Up to 72 hours


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Ultra Long-Acting

Analgesia

Neosaxitoxin


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One of a group of natural neurotoxic alkaloids,

commonly known as the paralytic shellfish toxins

(PSTs) © 2015 Dr. Stanley F. Malamed

All Rights Reserved

118



Neosaxitoxin

Long-acting local ANESTHETIC Long-acting local ANALGESIC

• Chile & Harvard © 2015 Dr. Stanley F. Malamed

All Rights Reserved

119



Neosaxitoxin

Over 1 week of analgesia (in rodents) without histologic or functional sequelae


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Now for a change of subject

121

Everybody is different

We teach ‘normal’ anatomy: Insert the needle here Advance 25 mms Aspirate Deposit the drug We HOPE the nerve is in the area

A basic truism regarding ANATOMY:


122

Once a needle penetrates the skin or mucous membrane,

every injection is BLIND

A basic truism regarding INJECTIONS:


123

LAs are chemicals that interrupt nerve conduction

(producing anesthesia) transiently

(hopefully)

A basic truism regarding LOCAL ANESTHETICS:


124

ALL LAs are neurotoxic (they can damage nerves)

Another truism regarding LOCAL ANESTHETICS


125


If all LAs were equally neurotoxic the % of cases of paresthesia would be

equal to the drugs % market share

50% of market share = 50% of cases of paresthesia25% of market share = 25% of cases of paresthesia

Ratio should be 1.0

% Cases of paresthesia% Market share

126

Paresthesia has existed ever since injections

were first administered

A basic truism regarding PARESTHESIA:


127

ARTICAINE © 2015 Dr. Stanley F. Malamed

All Rights Reserved

128


What, if any, are the clinical advantages of articaine HCl

compared with the other amide LAs?

129

1. More lipid-solubleDiffuses through soft & hard tissues betterPalatal anesthesia with buccal infiltrationMandibular anesthesia in adults via infiltration

AdvantagesArticaine HCl


130

Maxillary Infiltration


Flared palatal roots Palatal soft tissue

Articaine Articaine

131

Mandibular infiltrationJohn Meechan (UK)

Al Reader (USA)


Articaine HCl by Mandibular Infiltration in Adults

132

2. Elimination half-life of 27 minutes (162 min = 2:42) Lidocaine, mepivacaine, prilocaine ~ 90 minutes (540 min = 9 hrs)



133

3. PregnancyAll other amide local anesthetics

Beta half-life ~90 minutes +

ARTICAINE

Beta half-life 27 minutes



134



4. Nursing All other local anesthetics

Pump & discard for 9 hours*

ARTICAINE

Pump & discard for 4 hours*

USA FDA

USA FDA

135

5. Pediatrics - preferred LA Decreased risk of overdose

Elimination half-life of 27 minutes



136

Articaine is the LEAST LIKELY anesthetic to induce an overdose caused by administration of too many cartridges



137

6. Endodontics (infected / inflammed teeth)Greater lipid-solubility

Thiophene ring = articaineBenzene ring = other LAs



138

Benzene ring = LIPID SOLUBILITY

= LIPID SOLUBILITYArticaine

LidocaineMepivacaine

PrilocaineBupivacaine

Thiophene ring


139

7. ‘Hard to ‘numb’ patients (anecdotal)



140

1. More lipid-solubleDiffuses through soft& hard tissues betterPalatal anesthesia with buccal infiltrationMandibular anesthesia in adults via infiltration

2. Elimination half-life of 27 minutes (162 min = 2:42) Lidocaine, mepivacaine, prilocaine ~ 90 minutes (540 min = 9 hrs)

3. Pregnancy - preferred LA4. Nursing - ‘Pump & dump’ for 4 hours (FDA)

Lidocaine, mepivacaine, prilocaine P&D for 9 hours5. Pediatrics - Lesser risk of OD6. Endodontics (infected/inflammed teeth)7. ‘Hard to ‘numb’ patients (anecdotal)



141

So, Malamed, you think articaine is a

great drug, but . . .


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Are there any concerns,out there in the community,

regarding articaine HCl?

YESProlonged anesthesia

(paresthesia) © 2015 Dr. Stanley F. Malamed

All Rights Reserved

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Articaine and

Paresthesia

Just the Facts

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Haas, D A. Lennon, D.A 21 year retrospective study of reports of paresthesia

following local anesthetic administration.J. Canadian Dental Association). 61(4):319-20, 323-6, 329-30, 1995

Overall incidence of paresthesia (all LAs) = 1:785,000

2% and 3% LAs = 1:1,250,000

4% prilocaine = 1:588,235

4% articaine = 1:440,529 (0.000000227%) (2.2699e-06)

Ontario, Canada

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Mepivacaine 1:623,112,900

Lidocaine 1:181,076,673

Bupivacaine 1:124,286,050

OVERALL 1:13,800,970

Articaine 1:4,159,848

Prilocaine 1:2,070,678

USA

(0.000000024%)(2.403934e-07)

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Pogrel MAJ. Calif Dent Assoc 40:795-797, 2012 (October)

2012

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2007 2012

Lidocaine 0.64 0.5

Articaine 1.19 0.97

Mepivacaine 2.2

Prilocaine 4.96 3.25

M. Anthony Pogrel, DDS, MD

1.0 is expected

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Author Country Year %Lingual

Haas, Lennon Canada 1995 70.6

Hillerup Denmark 2006 77

Kingon, Sambrook Australia 2011 80

Garristo, Haas USA 2010 92.7

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So, why is it that the lingual nerve is primarily involved in cases of

paresthesia?


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“The Lingual Nerve is In the Way”


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IMO . . . IF it’s the distribution of the lingual nerve (loss of taste, paresthesia) . . .

It’s MECHANICAL

Not chemical

Professor Dr. Stanley F. Malamed

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Paresthesia in dentistry

> 95% of reported cases occur in the MANDIBLE

Of these the overwhelming percentage involve only the lingual nerve

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Is rarely observed in the maxilla< 5%Yet 1/2 of all dental care is in the upper arch


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Is rarely (no reported cases) observed following:

Gow-Gates mandibular nerve block

Vazirani-Akinosi mandibular nerve block

Only occasionally following mental/incisive nerve block

No lingual nerve in area


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Articaine is used in medicine:NO reports of paresthesia from articaine following use in medicine

Paresthesia and 4% Anesthetics

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Question:

Is it possible that articaine is so specifically neurotoxic that it only affects nerves within the mouth and more specifically the lingual nerve?

Answer:

NO !

Paresthesia and 4% Anesthetics

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So, what should YOU do?

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The doctor MUST always consider the BENEFIT to be gained from use of a procedure or drug versus the RISK involved in the procedure or drug.

ONLY when the benefit to be gained CLEARLY OUTWEIGHS the risk should the procedure be done or the drug administered

Benefit v. Risk

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ALL reports claiming an increased risk of paresthesia with articaine are

ANECDOTAL

There is absolutely NO scientific evidence articaine has a greater risk

of paresthesia than other LAs

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Continue to use Articaine by IANB blockIF you are unconvinced:

Use Lidocaine or Mepivacaine for IANBNOT Prilocaine

Follow Lidocaine IANB with Articaine buccal infiltrationAt apex of tooth being treated½ cartridge

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Continue to use Articaine by IANB block

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IF you are unconvinced:Use Lidocaine or Mepivacaine for IANB

NOT PrilocaineFollow Lidocaine IANB with Articaine buccal infiltration

At apex of tooth being treated½ cartridge

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LOCAL ANESTHESIA Update

Stanley F. Malamed, DDS Dentist Anesthesiologist


Los Angeles, California, USA

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Thank you for listening . . .

[email protected]

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LOCAL ANESTHESIA Update