Full Mouth Extractions with 10 carpules? How?

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I am a practicing general dentist. I do a lot of extractions. I have frequently heard the "10 carpules" rule for full mouth extraction case. However, by the time I numb the upper arch, I already used 7-8 carpules of lidocaine.

Does anyone know how to and where to properly numb the patient with 10 carpules or no more than 10 carpules of lidocaine 2% 1 in 100k epi?

Is it safe to use more than 10 caupules?

Please advise.

Thanks

Originally Posted by Dentoxin

I am a practicing general dentist. I do a lot of extractions. I have frequently heard the "10 carpules" rule for full mouth extraction case. However, by the time I numb the upper arch, I already used 7-8 carpules of lidocaine.

Does anyone know how to and where to properly numb the patient with 10 carpules or no more than 10 carpules of lidocaine 2% 1 in 100k epi?

Is it safe to use more than 10 caupules?

Please advise.

Thanks

This does require some skill cause frankly, if you miss a block, then you've wasted a carp.

For a full mouth extraction, I would usually do the following:

Right PSA: 3/4 carp
#4 Infil: 1/2 carp
#6 Infil: 1/2 carp
#8 Infil: 1/2 carp
Greater Palatine: 1/4 carp
Nasopalatine: 1/4 carp
Same for the left
Total for upper arch: 5-6 carps

Right IA/Lingual: 1 carp
Right long buccal: 1/4 carp
same for the left
Total for lower arch: 2.5 carps

Total carps: about 8, giving you a couple carps to use as adjunctives for hot teeth.

But in all honesty, most full mouth extractions are already missing some teeth, and not every one of these is always needed, like if they are missing all the left lower molars, don't do a long buccal, or if 1-3 are gone, don't do a PSA. It's very patient dependent, some tend to have more tolerance than others to anesthetics too.

Anyway, the other trick is to wait...a lot of people rush in after injections, but often a tooth that hurts to elevate 10 minutes after an injection will not hurt at all if you just wait another 5 minutes.

Stupid question. Why not Gow-gates both sides of the mandible? This seems like it would save time and extra injections while achieving the same effect. Also you can use just 1 carp instead of 1 and a quarter....just a thought. In my limited experience, I've hit Gow-gates with much more predictability.

Originally Posted by EJsDad

Stupid question. Why not Gow-gates both sides of the mandible? This seems like it would save time and extra injections while achieving the same effect. Also you can use just 1 carp instead of 1 and a quarter....just a thought. In my limited experience, I've hit Gow-gates with much more predictability.

I have no good answer for you. I just feel more comfortable doing the IA. If I felt more comfortable with the GG because I did it more, then I'd probably do that. But I do go for the GG on occasion when I've missed the IA. However, I'm also not usually doing full mouth extractions, so most of the time I don't worry a lot about # of carps cause when I'm just doing a crown on #30 and a DO on #29, I don't worry if I only use 1 carp vs. 2 carps. It's a good point though, if you are doing a lot of extractions, going to the GG is a way to cut down on carps and get all the nerves together.

Originally Posted by Dentoxin

I am a practicing general dentist. I do a lot of extractions. I have frequently heard the "10 carpules" rule for full mouth extraction case. However, by the time I numb the upper arch, I already used 7-8 carpules of lidocaine.

Does anyone know how to and where to properly numb the patient with 10 carpules or no more than 10 carpules of lidocaine 2% 1 in 100k epi?

Is it safe to use more than 10 caupules?

Please advise.

Thanks

Not a dentist, but each 2% carpule contains 36 mg of lido. The tox dose for lidocaine is 4.4 mg/kg of lido without epi, and up to 7mg/kg with epi. Using 10 carpules give you 360 mg of lido, which can you can give to the 'standard' 80 kg patient. Lido with epi, you can give up to 560 mg for the 'standard' 80 kg patient, or about 15 carpules. But I'd read the package insert for specific dosage ranges.

Originally Posted by EJsDad

Stupid question. Why not Gow-gates both sides of the mandible? This seems like it would save time and extra injections while achieving the same effect. Also you can use just 1 carp instead of 1 and a quarter....just a thought. In my limited experience, I've hit Gow-gates with much more predictability.

I agree with you on the Gow-gates, I used to use it all the time with great success and less lidocaine.

Bilateral palatine V2 blocks: 2 carps
Bilateral IALNB + buccal: 2.5 carps

Less than most people use for 2 quads of SRP. Note you don't get local vasoconstriction with this for bleeding control, so if you have some 2% lido with 1:50,000 around it'd be good to do some small local infiltrations.

If it takes you 7-8 carps to numb up the max you are doing something very wrong

And if you hit both ianb's the mandible takes no more than 3-4 carps for profound

Originally Posted by armorshell

Bilateral palatine V2 blocks: 2 carps
Bilateral IALNB + buccal: 2.5 carps

Less than most people use for 2 quads of SRP. Note you don't get local vasoconstriction with this for bleeding control, so if you have some 2% lido with 1:50,000 around it'd be good to do some small local infiltrations.

Armorshell, we can't all roll hardcore with the V2 block I think you should just push that 27 long to the hub and give them a CN V block I see your posts on here all the time, where are doing your residency?

I have no excellent response for you. I just experience more relaxed doing the IA. If I sensed more relaxed with the GG because I did it more, then I'd probably do that. But I do go for the GG on situation when I've skipped the IA. However, I'm also not usually doing complete lips extractions, so most of time I don't get worried a lot about # of carps cause when I'm just doing a title on #30 and a DO on #29, I don't get worried if I only use 1 carp vs. 2 carps. It's a excellent thing though, if you are doing a lot of extractions, going to the GG is a way to cut down on carps and get all the nerve fibres together.

Originally Posted by EJsDad

Armorshell, we can't all roll hardcore with the V2 block I think you should just push that 27 long to the hub and give them a CN V block I see your posts on here all the time, where are doing your residency?

Agreed. We can't all be DDS, MD oral surgeons. Some of us still infiltrate

Originally Posted by djeffreyt

Agreed. We can't all be DDS, MD oral surgeons. Some of us still infiltrate

No one else I know does this (OMS included), and I learned the technique I use from a general dentist. I think it's an awesome. easy block that's way underutilized.

i personally never do max and mand full mouth ext's. i always do the max ext's and del the upper immediate. give the pt two weeks and then do the same on the lower. a lot more comft for the patient.

Originally Posted by omaralt

i personally never do max and mand full mouth ext's. i always do the max ext's and del the upper immediate. give the pt two weeks and then do the same on the lower. a lot more comft for the patient.

This is what I've seen as well, but I guess it depends on the state of the pt in most cases.

Originally Posted by omaralt

i personally never do max and mand full mouth ext's. i always do the max ext's and del the upper immediate. give the pt two weeks and then do the same on the lower. a lot more comft for the patient.

Also different if they've been waiting 6 months for their appointment and aren't getting dentures.

Originally Posted by tkim

Not a dentist, but each 2% carpule contains 36 mg of lido. The tox dose for lidocaine is 4.4 mg/kg of lido without epi, and up to 7mg/kg with epi. Using 10 carpules give you 360 mg of lido, which can you can give to the 'standard' 80 kg patient. Lido with epi, you can give up to 560 mg for the 'standard' 80 kg patient, or about 15 carpules. But I'd read the package insert for specific dosage ranges.

It's recommend staying under 0.4mg of epi. With 1:100,000 and a 1.8ml dental carpule, you're looking at 0.018mg. It works out to 11 carpules max in this case due to the vasoconstrictor and not the local anesthetic as you mentioned. Not always true. Saying max "10 carpules" is a nice even number to remember with a little buffer of safety.

Originally Posted by armorshell

No one else I know does this (OMS included), and I learned the technique I use from a general dentist. I think it's an awesome. easy block that's way underutilized.

Which approach do you use?

Originally Posted by WannaBeDentist

It's recommend staying under 0.4mg of epi. With 1:100,000 and a 1.8ml dental carpule, you're looking at 0.018mg. It works out to 11 carpules max in this case due to the vasoconstrictor and not the local anesthetic as you mentioned. Not always true. Saying max "10 carpules" is a nice even number to remember with a little buffer of safety.

You can give 22 carpules without hitting 0.4 mg epi, not 11.

Here's what I do..did a full mouth case a few months back: 27 teeth

a) IAN blocks LL and LR (1.5 carpules each)
b)1 carpule for mental nerve block and lower anterior infiltration bilateral
c) PSA block 1 carpule each side
d) 2.5 carpules for upper premolars
e) 2 carpules for upper anterior infiltration
f) anterior access openings (endo style and intracanal injections for all upper anterior teeth after infiltrations take effect) .5 carpules
g) long buccal injection (.5 carpules)

3+1+2+2.5+2+.5+.5 = 11.5 carpules

Originally Posted by tkim

You can give 22 carpules without hitting 0.4 mg epi, not 11.

That was a typo, it should've said 0.2mg of epi *slaps forehead*

Originally Posted by armorshell

No one else I know does this (OMS included), and I learned the technique I use from a general dentist. I think it's an awesome. easy block that's way underutilized.

Have you ever tried high tuberosity approach? I've tried palatine approach in the past several times but had limited success, maybe I was just not patient enough for it to set in. Will try both in clinic some more in the future.

I've had the opposite experience. I've never been able to make the 'high PSA' work to my liking, but I can't remember missing with the palatial approach.

I do lean the patient way back in the chair after dumping all my blocks in, then give them a solid 10 minutes to soak while I do some paperwork or go see another pt.

Originally Posted by tkim

Not a dentist, but each 2% carpule contains 36 mg of lido. The tox dose for lidocaine is 4.4 mg/kg of lido without epi, and up to 7mg/kg with epi. Using 10 carpules give you 360 mg of lido, which can you can give to the 'standard' 80 kg patient. Lido with epi, you can give up to 560 mg for the 'standard' 80 kg patient, or about 15 carpules. But I'd read the package insert for specific dosage ranges.

It would be nice to review the literature that talk about maximum dosage and toxicity. Do you have one or does anyone know?

Thanks

http://www.amazon.com/Handbook-Local.../dp/0323024491

Originally Posted by tkim

Not a dentist, but each 2% carpule contains 36 mg of lido. The tox dose for lidocaine is 4.4 mg/kg of lido without epi, and up to 7mg/kg with epi. Using 10 carpules give you 360 mg of lido, which can you can give to the 'standard' 80 kg patient. Lido with epi, you can give up to 560 mg for the 'standard' 80 kg patient, or about 15 carpules. But I'd read the package insert for specific dosage ranges.

Could you explain why you can use more " lido with epi" carpules, 15. Whereas, you can only use 10 "plain lido" caruples in this case?

Thanks

Originally Posted by armorshell

I've had the opposite experience. I've never been able to make the 'high PSA' work to my liking, but I can't remember missing with the palatial approach.

I do lean the patient way back in the chair after dumping all my blocks in, then give them a solid 10 minutes to soak while I do some paperwork or go see another pt.

Hey I just went to a meeting at the Western Regional Dental Convention that discussed the use of Bicarbonate with Lido or other anesthetics to decrease the acidity needed to preserve the solution w/ epi long term. It seemed like a good idea and my classmate who's father is a physician said he's been using this approach for years. Essentially you expel like half a carp and load bicarb making sure not to neutralize too much or your anesthetic will crystalize out of solution. This approach is supposed to cut your waiting time out of the equation as the neutral solution leaves anesthetic in the unprotonated form, allowing anesthetic into the nerve faster. Just wondering if anyone has ever used this

Originally Posted by Dentoxin

Could you explain why you can use more " lido with epi" carpules, 15. Whereas, you can only use 10 "plain lido" caruples in this case?

Thanks

Epi = vasoconstrictor...prevents it from going to LAST

Originally Posted by Dentoxin

It would be nice to review the literature that talk about maximum dosage and toxicity. Do you have one or does anyone know?

Thanks

http://emedicine.medscape.com/article/1844551-overview

Originally Posted by DrTacoElf

Have you ever tried high tuberosity approach? I've tried palatine approach in the past several times but had limited success, maybe I was just not patient enough for it to set in. Will try both in clinic some more in the future.

Haha, the palatine approach seems pretty intense to me. Certainly a small target to hit. I'm hoping to learn the high tuberosity approach before I graduate.

Having said that that though, I've had decent success numbing the entire maxilla with Septocaine 4% (1:100k epi) using a long needle and a lateral approach where you penetrate the vestibular mucosa perpendicular to the long axis of the teeth near the apices of the teeth and insert until you're almost at the neck. Then deposit as you withdraw. Without infection, 4 carpules did the trick. Also, Septo I feel is pretty strong stuff when infiltrating. No need for Greater palatine or Incisive nerve block. Though you can probably supplement with a carp or two of Xylocaine 2% for the block if you feel you need it. (based on the literature, I don't like blocking with Septocaine).

Though FYI, I have never done a full mouth extraction... only one jaw.

Originally Posted by EJsDad

Hey I just went to a meeting at the Western Regional Dental Convention that discussed the use of Bicarbonate with Lido or other anesthetics to decrease the acidity needed to preserve the solution w/ epi long term. It seemed like a good idea and my classmate who's father is a physician said he's been using this approach for years. Essentially you expel like half a carp and load bicarb making sure not to neutralize too much or your anesthetic will crystalize out of solution. This approach is supposed to cut your waiting time out of the equation as the neutral solution leaves anesthetic in the unprotonated form, allowing anesthetic into the nerve faster. Just wondering if anyone has ever used this

http://www.onpharma.com

Spoke with the CEO of the company one day at our dental school... Sounds interesting but might add too much cost to LA administration?

I'm a huge fan of the pterygopalatine ganglion block. I routinely do these in the clinic. Malamed has some stuff regarding the angle of the GPC. When I started, I always assumed it was almost perpendicular to the hard palate which is not the case. I don't know his numbers off hand (look it up in his local anesthesia book), but the GPC is somewhere in the ballpark of 60-75 degrees from perpendicular to the hard palate. I've also read a paper that I can't find for the life of me regarding complications of traversing the GPC. It covered major complications of the block. I've personally had two patients with transient vertical diplopia and one where I sent the needle through the wall of the canal.






Surg Radiol Anat. 2005 Dec;27(6):511-6. Epub 2005 Oct 15.
Anatomy of greater palatine foramen and canal and pterygopalatine fossa in Thais: considerations for maxillary nerve block.
Methathrathip D, Apinhasmit W, Chompoopong S, Lertsirithong A, Ariyawatkul T, Sangvichien S.

I do the V2 often as well. The more you do it the easier it gets.