Articaine for IAs?

[SeattleRDH]

Is this a no-no? I almost always use lido w/ epi or carbocaine but I know some people use Articaine for mandibular blocks. I'm not sure how I feel about that. Anyone?

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[peg lateral]

Is this a no-no? I almost always use lido w/ epi or carbocaine but I know some people use Articaine for mandibular blocks. I'm not sure how I feel about that. Anyone?

I have yet to do so myself, but I know a lot of general dentists and oral surgeons who do. We were taught in school that it was a no-no, but I am not so sure. The dentists I have talked to that use it for everything are having different results in their offices than what the research shows. The thing is, paresthesia can result from any type of dental injection-- so I don't know if there really is a reason not to use it, except maybe cost.

 

[HupHolland]

Research shows that articaine IAN block is no more effective than lidocaine.

Also, virtually all the research shows that articaine can be used safely for IAN without increased risk of paresthesia. Key word: virtually. There is a study out there that states articaine is not as safe.

Now, if lidocaine is just as effective, why not just use it for blocks and call it a day?

Hup

 

[tinman831]

Why bother taking the risk when there are plenty of other effective anesthetics out there? No studies have conclusively shown a definitive link between Septo and paresthesia, but the name Septocaine seems to pop up a lot. You don't want to get that call from your patient saying that shes still numb two days later.

 

[DrJeff]

Mandibular extractions or endo's - I'm loading my syringe with Articaine. Been doing that for about 5 years now. Both the primary oral surgeon and endodontist I refer to do the same. No cases of paresthesia from any of us. In theory if myself as the GP is held to the standards of a specialist, I feel pretty comfy grabbing for the articaine in those cirumstances I mentioned

 

[Toofdr]

We've been covering this subject extensively in one of our classes. The cause of paresthesia after IA blocks is not really know as you may know. However, many many studies have been conducted over the past few decades and it has been shown that when paresthesia has been reported it occurred more often using articaine and prilocaine over other anesthetics for IA blocks. It has to be said though that it can happen with any anesthetic but speculation can only be made as to why or how it happens. The extrapolated incidence values suggest that almost every practicing dentist could have at least 1 paresthesia case in their career. Some decent reviews are on pubmed that make good points/debates.

 

[DrJeff]

We've been covering this subject extensively in one of our classes. The cause of paresthesia after IA blocks is not really know as you may know. However, many many studies have been conducted over the past few decades and it has been shown that when paresthesia has been reported it occurred more often using articaine and prilocaine over other anesthetics for IA blocks. It has to be said though that it can happen with any anesthetic but speculation can only be made as to why or how it happens. The extrapolated incidence values suggest that almost every practicing dentist could have at least 1 paresthesia case in their career. Some decent reviews are on pubmed that make good points/debates.

Lets think about what this means in REAL terms for a GP. I'll use myself for an example. On average I treat patients 200 days a year. On a typical day I'll average giving 5 IAB's, so that's 1000 IAB's/year, roughly 25% with articaine the last 6 years I've been using it. I've been in private practice for a little over 12 years now, and to my knowledge, I've never had an incident of permanent IAB parasthesia (the only permanent IAB parasthesia of any of my patients that I'm aware of was in a 3rd molar case where the wizzy was all over the IA canal radiographically and had a dentigerous cyst around it requiring my local oral surgeon to extract it and in doing so the IA nerve was damaged, as the patient was told pre surgery that it very likely would be). So I'm 0 for 1,500 an counting with articaine. Using the same basic numbers, my business partner is 0 for 20,000 and counting - figure another 1500 with articaine. So between us we're 0 for 32,000 overall and 0 for 3000 with articaine. I don't think that our experiences are that different from mot other doc's using articaine for IAB's. You just have to critically look at the data and then make an objective decision for yourself at what an "acceptable risk" is for you and your patients

 

[Toofdr]

Lets think about what this means in REAL terms for a GP. I'll use myself for an example. On average I treat patients 200 days a year. On a typical day I'll average giving 5 IAB's, so that's 1000 IAB's/year, roughly 25% with articaine the last 6 years I've been using it. I've been in private practice for a little over 12 years now, and to my knowledge, I've never had an incident of permanent IAB parasthesia (the only permanent IAB parasthesia of any of my patients that I'm aware of was in a 3rd molar case where the wizzy was all over the IA canal radiographically and had a dentigerous cyst around it requiring my local oral surgeon to extract it and in doing so the IA nerve was damaged, as the patient was told pre surgery that it very likely would be). So I'm 0 for 1,500 an counting with articaine. Using the same basic numbers, my business partner is 0 for 20,000 and counting - figure another 1500 with articaine. So between us we're 0 for 32,000 overall and 0 for 3000 with articaine. I don't think that our experiences are that different from mot other doc's using articaine for IAB's. You just have to critically look at the data and then make an objective decision for yourself at what an "acceptable risk" is for you and your patients

Great point, we can look at numbers and data all day but in the end you do have to step back and realize that we really don't know the mechanism of damage and that the numbers given in the studies are extrapolated values. I mean what procedures/medications that we deal with every day don't carry SOME risk of any kind?

 

[caffeinehigh]

Why bother taking the risk when there are plenty of other effective anesthetics out there? No studies have conclusively shown a definitive link between Septo and paresthesia, but the name Septocaine seems to pop up a lot. You don't want to get that call from your patient saying that shes still numb two days later.

I agree with this statement. I'd be trying adjunct anesthesia such as PDL or Intraosseous before giving an IAN block with 4% articaine.

 

[DrJeff]

I agree with this statement. I'd be trying adjunct anesthesia such as PDL or Intraosseous before giving an IAN block with 4% articaine.

FYI, *most* patients tend to appreciate the LEAST amount of times you uncap that needle (which in the eyes of many of your patients looks to be the size of a harpoon! ), even if you can give an extremely comfortable injection, most patients will have a slight (or sometime BIG) increase in their anxiety level every time you go to give them an injection.

Whether is actual or psychosomatic, I don't know? But atleast in my patients, in my practice for the last 6 or so years, Articaine has been a GREAT anesthetic to have in my collection that has become my beloved standard for just about any endo or extraction that I do in any region of the mouth. Heck, I literally just about 20 minutes ago finished up COMFORTABLY doing pulpectomies on HOT #'s 18 and 19 with some moderate extra-oral swelling with my favorite "hot tooth anesthesia cocktail" which is a carpule of 0.5% Marcaine 1:200,000 epi followed with a carpule of 4% Articaine 1:100,000 epi - I find that that combo gives BOTH profound pulpal anesthesia while I'm working on the tooth and then lingering anesthesia for an average of 4 to 6 hours post treatment which allows the patient to get some pain medication and/or antibiotics, and a comfortable meal into their system that the hot tooth(teeth) that caused me to choose that combo in the first place.

 

[jay47]

FYI, *most* patients tend to appreciate the LEAST amount of times you uncap that needle (which in the eyes of many of your patients looks to be the size of a harpoon! ), even if you can give an extremely comfortable injection, most patients will have a slight (or sometime BIG) increase in their anxiety level every time you go to give them an injection.

Whether is actual or psychosomatic, I don't know? But atleast in my patients, in my practice for the last 6 or so years, Articaine has been a GREAT anesthetic to have in my collection that has become my beloved standard for just about any endo or extraction that I do in any region of the mouth. Heck, I literally just about 20 minutes ago finished up COMFORTABLY doing pulpectomies on HOT #'s 18 and 19 with some moderate extra-oral swelling with my favorite "hot tooth anesthesia cocktail" which is a carpule of 0.5% Marcaine 1:200,000 epi followed with a carpule of 4% Articaine 1:100,000 epi - I find that that combo gives BOTH profound pulpal anesthesia while I'm working on the tooth and then lingering anesthesia for an average of 4 to 6 hours post treatment which allows the patient to get some pain medication and/or antibiotics, and a comfortable meal into their system that the hot tooth(teeth) that caused me to choose that combo in the first place.

It's funny that you bring this up. I've had 2 patients just this last week with teeth that just wouldn't go numb ("hot teeth" ) and the faculty couldn't get em numb either. I infiltrated on the buccal using 4% Articaine (#18 and #30) on the mandible and boom- tooth went numb less than 2 minutes later. I do think that I have good technique with the IAN, but when other stuff doesn't work, I go for articaine the teeth fall asleep.

 

[Streetwolf]

The problem is that when your patient gets paresthesia from a septo IANB, despite it being from the injection itself and NOT the anesthetic used, the lawyers will have a field day with the lawsuit. I bet they'd have a much easier time coming up with a case against the dentist who used septo than the dentist who used lido.

In my opinion lido works just as well, so why not stick with it? I'll certainly give a supplemental septo infiltration if needed.

 

[ogopogodude]

Why would it be a "no-no" for an I.A. block (mandibular block) using articaine? I have been doing this each and every day for over a decade.

I have taken everything that I have learned from dental school and thrown it out the window... It is continuing education that one REALLY learns how do perform dentistry, ....

 

[Toofdr]

Why would it be a "no-no" for an I.A. block (mandibular block) using articaine? I have been doing this each and every day for over a decade.

I have taken everything that I have learned from dental school and thrown it out the window... It is continuing education that one REALLY learns how do perform dentistry, ....

+ evidence based dentistry?

 

[tinman831]

Why would it be a "no-no" for an I.A. block (mandibular block) using articaine? I have been doing this each and every day for over a decade.

I have taken everything that I have learned from dental school and thrown it out the window... It is continuing education that one REALLY learns how do perform dentistry, ....

There was a study several years back that hinted at an association between IANB performed with Septocaine and paresthesia. The study was inconclusive but until there's a definitive answer, you don't want to be on the wrong end of a malpractice lawsuit. Streetwolf is right. The first question they'll ask you in trial on a paresthesia case would be what anesthetic you used, and if you say Septo, they'll simply quote the results of that one obscure study back in the day and you're toast.

 

[DrJeff]

There was a study several years back that hinted at an association between IANB performed with Septocaine and paresthesia. The study was inconclusive but until there's a definitive answer, you don't want to be on the wrong end of a malpractice lawsuit. Streetwolf is right. The first question they'll ask you in trial on a paresthesia case would be what anesthetic you used, and if you say Septo, they'll simply quote the results of that one obscure study back in the day and you're toast.

But the issue is that now, even Stanley Malamed himself is questioning the validity of that 1 study. So if you have arguably the "guru" of anesthesia himself questioning the study, then that really calls into question the "beyond a reasonable doubt" that you'd be facing.

Additionally when you take a look at the parasthesia data for other anesthetics on an objective basis, the rate for septocaine vs. other anesthesthetics is essentially the same. Its the ability to take the time and critically evaluate the research that so many don't do.

The biggest thing personally that I do, is whenever anesthetizing via an IAB, and the patient gets that "jump"/"zing" that I'm sure we've all seen every once in a while once you've done a few IAB's, I just document that in the chart, since the reality is that the needle has found the IA nerve, and that more than anything is the likely cause of any parasthesia that might result. I do these whether I've got a carpule of 3% plain Carbocaine, 2% Lido with epi, 0.5% Marcaine, 4% Septocaine, whatever my anesthetic of choice is. And those patients always get a follow up call either later that day or the next day to make sure that things are fine sensory wise.

 

[HupHolland]

For now (guess I haven't been practicing long enough to form some opinions based on my clinical outcomes) I'm on the tinman/streetwolf bandwagon.

Paresthesia aside, the research is pretty cut-and-dry on the effectiveness of septocaine vs. lidocaine for IAN block. There is not a statistically significant difference.

So, I might as well save some money (lidocaine is cheaper!) and the potential hassle of defending myself in court.

Hup

 

[Mackchops]

I think it's overboard to use septo for everything - just as I think it's silly to avoid it completely (*cough* my dental school *cough*). I think part of being a good dentist (in my super limited experience) is having a bunch of different tools in your toolbelt for different situations. I like that Dr. Jeff has septo for cases where, in his hands, he gets more reliable and profound anesthesia. It has it's place in his practice, even for blocks.

 

[jay47]

There was a study several years back that hinted at an association between IANB performed with Septocaine and paresthesia. The study was inconclusive but until there's a definitive answer, you don't want to be on the wrong end of a malpractice lawsuit. Streetwolf is right. The first question they'll ask you in trial on a paresthesia case would be what anesthetic you used, and if you say Septo, they'll simply quote the results of that one obscure study back in the day and you're toast.

Just use Lido for IAN and then supplement with infiltration with Septo on the buccal for molars, buccal and lingual for anteriors. You avoid almost all possibility of nerve damage with the septo by infiltrating on the mandible, and gain all it's usefulness. The latest numbers from the Supplement to the JADA showed that Septo has a nearly double rate of effectiveness in pulp testing for buccal infiltration @ 1.8ml in 1st molars (~65% vs ~35%). Couple that with a properly placed IAN and soft tissue anesthesia and you have a numb tooth (unless it was hot to begin with).

 

[jay47]

I think it's overboard to use septo for everything - just as I think it's silly to avoid it completely (*cough* my dental school *cough*). I think part of being a good dentist (in my super limited experience) is having a bunch of different tools in your toolbelt for different situations. I like that Dr. Jeff has septo for cases where, in his hands, he gets more reliable and profound anesthesia. It has it's place in his practice, even for blocks.

I think it is a slap in the face to all the students and patients at the school to not use it at all. It CLEARLY can play a role in relieving pain when other methods fail. In fact, it has saved my butt several times when a mandibular tooth won't get numb. I could understand not using it for IAN's just because of one disputed study a long time ago- but to not have it is just plain dumb IMO.

 

[DrJeff]

I think it's overboard to use septo for everything - just as I think it's silly to avoid it completely (*cough* my dental school *cough*). I think part of being a good dentist (in my super limited experience) is having a bunch of different tools in your toolbelt for different situations. I like that Dr. Jeff has septo for cases where, in his hands, he gets more reliable and profound anesthesia. It has it's place in his practice, even for blocks.

It's all about getting the proper paring of anesthetic, patient, and procedure IMHO. If you look in the anesthesia drawer in the cabinetry of all my treatment operatories, what you'll find is not 1, not 2, not 3, not 4, but 5 different types of local anesthetic. 3% Carbocaine without vasoconstrictor, 2% Carbocaine with 1:20,000 Levonordeferin as a vaso, 2% lidocaine with 1:100,000 epi, 0.5% Marcaine with 1:200,000 epi and 4% Septocaine with 1:100,000 epi.

Which 1 I choose to use depends on the type of procedure I'm doing (extraction/endo on a "hot" tooth tends to have different anesthesia needs than a small class II restoration on a premolar), how long I want the patient numb for (is it going to be a quick visit, a long visit, do I want them numb for a while after so that they can get some meds onboard before the anesthesia wears off, etc) and also is there any hypertension issues that I may be concerned about. When I've surveyed the situation infront of me, that's when I'll grab type I feel will work the best for me to comfortably finish the work that I need to on that patient. In my mind, local anesthesia administration most certainly isn't "one size fits all"