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dealing with pain while performing extractions

Discussion in 'Dental' started by groker2009, Jun 4, 2009.

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  1. groker2009

    groker2009

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    This sometimes happens when I extract lower molars. ( also on upper posteriors but to a lesser extent )

    Whenever I try inserting an elevator within the interdental papilla of the tooth to be extracted, the patient starts complaining of pain or discomfort.

    Other than that, the patient does feel numb. My block injections are usually successful, as my patients generally admit feeling numb to the midline of their lips. For difficult molar exos, I use at least 4 carpules of lidocaine.

    I usually only have topical gel, lidocaine, and short/long needle as my anesthetizing armamentarium. I don't have anything like articaine, PDL injection guns, etc so I have to make do with what I have.

    What should I do for pain control when patients complain of pain whenever I stick in an elevator in between teeth?
  2. armorshell

    armorshell Moderator Emeritus

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    Two possibilities as far as I can see:

    1. The patient is not numb. This seems unlikely as they're reporting numbness to the midline, and I have a hard time believing every patient you extract lower molars on has accessory innervation.

    2. The patient is feeling the wedging "pressure" of the elevator and reporting it as pain.
  3. armorshell

    armorshell Moderator Emeritus

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    Just for my own curiosity, do you actually insert the elevator directly into the papilla?
  4. aegdboy

    aegdboy

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    Even for my toughest patient, I rarely use 4 carps of lido.

    I use one full one for block and then another full one for PDL and local around the tooth. Just be careful on the lingual since the nerve runs there and there is some considerable biologic variance for its location.

    2 carps and most patients I extract that lower molar in 5min- 10 max. Good elevation is the key! If I take more than 10 min I open a flap to help me out.
  5. groker2009

    groker2009

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    Well, you can't insert it directly into the papilla or else you'll end up injuring it. Usually you would try inserting it in between the teeth within the cervical regions, which is in the vicinity of the papilla.
  6. aegdboy

    aegdboy

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    Oh, try septocaine.

    Patients get pretty profound anesthesia from it. I have never done it, but I have assisted others that have extracted lower molars with just local septocaine.
  7. groker2009

    groker2009

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    The same thing sometimes happens to me when I'm doing an upper molar exo. Especially when I wedge my elevator in between the teeth and try to move it within the roots, the patients would cringe.

    So what should I do?
  8. Thaxil

    Thaxil Senior Member

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    This could be hard to determine at times. What I often do before beginning is stick the patient in the gums next to the tooth; if it goes unnoticed it is just the discomfort from the pressure. Many patient are just too nervous to proceed, I think they perceive pain when none is there. I have used nitrous to calm them in this situation. On rare occasion, I can’t work on a patient because they are just crazy, and I know they are numb.
  9. groker2009

    groker2009

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    So your patients don't struggle when you're elevating a strong lower molar? And what do you mean by giving a PDL injection and a local injection "around" the tooth?
  10. armorshell

    armorshell Moderator Emeritus

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    That's why I concluded it's probably just pressure. Ask them if it's a sharp, stinging pain or if it just feels weird. This happens all the time and 9/10 times they just didn't understand that what they were feeling was normal and they thought something was wrong.
  11. dr.rex

    dr.rex rexadactyl nights

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    i hope you are asking the pt. if they are feelin pain when they make a weird face b/c they are going to say yes. just keep elevating until they pull their head away thats when i feel like they have just felt some pain. the pressure will make anyone give a weird face
  12. tinman831

    tinman831 ¯\_(ツ)_/¯ Administrator SDN Senior Moderator Lifetime Donor

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    PDL injection as in insertion of the needle into the PDL space and injecting there. Local injection is just infiltration around the tooth in question.
  13. armorshell

    armorshell Moderator Emeritus

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    This is why I close my eyes when I extract teeth, to avoid any distractions.
  14. aegdboy

    aegdboy

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    A good extraction is not about how much force, but how you apply needed force.

    I always do an extraction with an assistant so that they can support the pt, meaning like mand, etc.

    By them holding the mand., I can concentrate the forces where I need them instead of pushing the pt around. Remember for every action there is an opposite and equal reaction.

    So if you waste your energy on the mand moving down, the pt will struggle.

    Granted I have only done about 200 extractions, my pt's rarely struggle even for that "tough" molar.

    If it is that "tough" I follow the rule "divide and conquer". Like I said before, if it takes more than 10 min, I will open a flap. At that point I re-evaluate and will probably section the tooth. The less traumatic the extraction the better.

    If you sit there pull and poke and nothing is moving, well then you will do more damage than good.
  15. aegdboy

    aegdboy

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    as tinman stated, just drive the needle into the PDL. Its tough but works good.

    I used to only do it when the pt said they still felt discomfort. Now I just do it on every extraction.

    This way the pt is more at ease since they never felt the discomfort and wanted more anesthesia.
  16. bigfish

    bigfish

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    Try using 2% lido with 1/50 K epi--Septocaine can cause unwanted paresthesias, especially in the mandible. Give your block then inject on the lingual of the mandible, in the FLOOR of the mouth opposite the tooth, you get some aberant innervation from that area, then, inject in the long buccal area adjacent the buccal of the tooth and infiltrate then go back and blanch the soft tissue on the facial in the area of he CEJ. Your extraction will be a slam dunk--no problems and as others have said, inform the patient that they will feel pressure, not pain, if they feel pain try a PDL injection along the MB root--works for me, 37 years using this method, try it!
  17. aphistis

    aphistis Moderator Emeritus

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    Routinely needing four carps of lidocaine for a molar extraction tells me the first thing you ought to do is review your injection technique, because you're not putting the lidocaine in the right place. I plan most of my full-mouth extractions for 8 cartridges of anesthetic (bilateral Gow-Gates+IANB one cartridge each injection, bilateral V2 one cartridge each injection, two cartridges for touch-ups PRN). If you're positioning your needle properly, you should predictably be able to obtain profound anesthesia with two carps of local.

    The septocaine-paresthesia controversy has been discussed here previously, and I commented extensively in that thread. Interested parties should be able to find it by searching the forum. Short version: Septocaine is an excellent drug and too many dentists are unnecessarily afraid of it, to their patients' detriment.

    PDL's are highly effective supplemental injections. Remember, though, you have to really apply some force to push the needle into the space. If you aren't getting a good thumb workout from your PDL's, you aren't doing them right. Backpressure, backpressure, backpressure.

    Bigfish makes an excellent point regarding contralateral innervation, particularly for anterior teeth. havin said that, while profound anesthesia is a necessary starting point for a successful extraction case, achieving good anesthesia does not automatically imply that the rest of the procedure will go smoothly.

    Good clinical threads so far, groker. :thumbup:
  18. ou_jay

    ou_jay Junior Member

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    I can think of two possibilities:

    1.) Are you giving a long buccal nerve block? It could be facial soft tissue.
    2.) Are you very firmly supporting the patient's jaw? Sometimes the pressure causes pain in the TMJ if you don't support the jaw completely.
  19. Yellow Snow

    Yellow Snow Senior Member

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    This is the first thing I thought of too.
  20. mike3kgt

    mike3kgt Hopefully scuba diving

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    This is absolutely #1 IMO and not taught enough in d-schools. I take out thousands of teeth a year and it took a while for me to figure out that my professors were nuts by telling me to "just keep rocking with the 151" for seemingly 45 minutes. Then after 45 minutes, you hear "CRACK" and you have to spend another 30 minutes fishing out a root tip (or punt to the OS prof / resident). After some private practice experience, I went to a CE course for extractions and the doc told me he doesn't even keep a 150/151 in his routine kit for extractions for pre-prosthetic implant extractions. If you have to use a pair of forceps to extract anything from 2nd bicuspid to 2nd bicuspid, try an Ash forceps or apical retention forceps. I was pleased how easily either works for EXT.

    I have amazed myself by how easily I can extract teeth by putting down the 150/151 until the very end (tooth is 3/4 out of the socket). With time, you can even "roll" out #3 or #14 or get it moving enough that a 150 just gently removes the tooth. Place the elevator long axis along with the long axis of the root you wish to elevate (i.e. a man bicuspid) and twist. It takes experience to learn how much a tooth can give before it snaps.

    On lower molars, I always put in 1 carp 2% lido 1:100kepi IANB and 1 carp 4% septo 1:100kepi (1/2 lingual, 1/2 buccal) infiltration. Works magic.
  21. DrTacoElf

    DrTacoElf

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    Make sure you are giving long buccal anesthesia and also consider supplementation on the lingual below and distal the molars in case the nerve to the mylohyoid is contributing. In addition I usually like to give some into the papilla directly until it blanches. Still with all this you should be only like 2.5 carpules assuming your block works.
  22. DrJeff

    DrJeff Senior Member Moderator

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    Lots of good replies here. One thing I'll hit on, that has been briefly mentioned in this thread already is the patient's perception of pain vs. pressure.

    What I do before I extract a tooth on any patient, is really give the the idea about what I'm referring to when I say "pressure" I make a fist, and using my knuckles, apply a decent amount of rubbing/twisting pressure to their shoulder - and then tell them that they can expect to feel that as I'm extracting their tooth. Often I'll apply a bit more pressure to their shoulder than I'd anticipate they'll feel during the extraction, so that when when the tooth comes out with less of a sensation of pressure, then I look even better in the eyes of the patient! :D

    With so many procedures, if you take an extra 30 seconds before starting to really explain what things will fell/sound like to the patient, things will very often go ALOT smoother:thumbup:
  23. teeth63a

    teeth63a Dharma Dentist

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    lots of good points here. I agree fish bigfish 100%.

    To add:

    I get the pt numb. Then I test to see the numbness with an explorer. I apply more if I need. I then explain to them that "You might feel pressure, and pressure is ok (I would press my fingers into their shoulder), but if it feels sharp you raise your hand and let me know".

    When I start, some people start cringing, but when I ask is it sore, they say "No I just hate that pressure".

    If I'm sounding the bone in the mental area with an explorer and the patient doesn't even budge, you've hit the IA block properly. But as soon as you start to elevate the molar and they say "Ow that hurts" I suspect extra innervation. A mentor once told me that the accessory nerve can throw a branch up to that area, which is why in your case I would put septocaine locally (but more in the plate area, not floor area) against the tooth, only because I know I'd get good saturation due to the thiness of the bone. Depositing in the PDL is good too, but can be transient.

    aegdboy gives himself 10 minutes, I give myself 2. If it ain't wiggly after 2 mins, I whip out the handpiece to section and trough.

    I've had one patient in my short 8 year career who absolutely couldn't get numb after the IA, local, PDL. Tooth was sectioned, and she felt the jolt as soon as the bur hit the pulp. And she practically lifted herself off the chair as I worked the tooth out. I finally told her, I got you as numb as best I can I just need you to bear with me. So I had a "By the power of Grayskull" moment, and muscled it out. She told me after that she had been on morphine for pain chornically for years but stopped recently. :mad: My point is, if all else fails, work fast and just get it out.
  24. aphistis

    aphistis Moderator Emeritus

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    1) The accessory nerve is a motor-only nerve. If a patient is getting some aberrant sensory innervation, it ain't coming from there.

    2) He-Man was (is?) awesome.

    3) Your anesthetic-proof lady is a great example of how opioid tolerance, plus withdrawal, can produce a significant hyperalgesia. For the students here, these are patients on whom you don't want to skimp when it comes to operative anesthesia and post-op analgesia. Nice job getting her numb enough to finish at all.
  25. groker2009

    groker2009

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    But what if the patient complains of pain when you stick in an elevator in between the lower molars and start to move it in apically? ( this is BEFORE the actual elevating action, with the patient admitting numbness to the midline of the lips )

    And what if the same patient ( with the same amount of numbness ) complains of even more pain when you finally try elevating the molar?

    Would you still classify the above two cases as having resulted from pressure? Or are they both due to an additional innervation? I find the latter hard to believe because this has been happening to me very frequently.

    And how exactly do you give an injection in the PDL? Is it akin to probing the perio pockets with the lido needle and giving various injections around the tooth?
  26. DrTacoElf

    DrTacoElf

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    In this case its probably accessory innervation as I posted above. Make sure long buccal is taken care of as well as distal and lingual of the molars. You do realize that the buccal soft tissue is not innervated by the inferior alveolar nerve right??
  27. teeth63a

    teeth63a Dharma Dentist

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    Agree 100%with DrTacoElf.

    If your pt is still feeling something, he's got accessory innervation. If its happening frequently, you have a lucky streak, or your patients aren't communicating to you properly how numb they are...some say they're numb when they're not, some will say they aren't when they are, which is why my trusty explorer does all the talking for me (ie exploer touch to the mental area)

    You are correct about the PDL. I was taught to give it at the corners of the teeth. Push into the sulcus until you come to a stop and press the plunger. Hard. It takes a lot of force to get fluid down there. It doesn't feel like you're giving anything, but it only takes fractions of a mL to do it.

    Case in point:
    2 hours ago, I just finished extractions on a 18yo male, #17, 32.

    2 carps each side to the IA got him numb, long buccal given as well. Tongue,
    mental area and buccal areas numb of #17,32.

    Envelope flap, distal wedge, no problem.

    Inserted elevator between #31,32 and commenced apical/distal force.
    Pt got squinty, I asked if it was pressure, he said yes.

    Elevated more, tooth visibly elevated out of socket, but not completely. Pt raised hand to say it hurt. I gave a local in the lingual area of #32. Decided to give PDLs as well. When I placed the needle apically into the sulcus at the mesial lingual corner, his eyes popped open cause he felt the jolt there. So I suspected accesory innervation (since lingual and IA were numb). After a minute, I tried again, and no problem, pt didn't flinch, the tooth popped out.

    And true to form, I needed to do the same thing on the left, with a PDL injection at the mesial buccal which finally got complete anesthesia.

    By the power of Grayskull, I truly did have the power.

    Hope this helps.

    ps- ok aphistis...so if its not the accessory, is it the hypoglossal?
  28. crazy_sherm

    crazy_sherm å♪▼æ╬‼▄·

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    How exactly are you numbing up the patient? Are you giving the IA, waiting for lip numbness to the lip midline, then giving the long buccal before you start? Or are you doing the IA and long buccal sequentially before verifying profound anesthesia? Where else are you infiltrating for supplemental anesthesia?

    Reason I ask is if you're giving supplemental injection before verifying that your IA has taken, then you might be flowing anesthetic close enough to the mental foramen that you are numbing mental nerve without complete IA block. This will give you a false positive that you got a successful IA block.
  29. armorshell

    armorshell Moderator Emeritus

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    How can this be accessory innervation if:

    A. This happens to him when working on the upper as well as the lower
    B. This is happening on every patient he works on in the lower

    The anatomical rate of accessory innervation to mandibular molars has been shown to exist in only 10-20% of patients. So unless to OP is practicing on some kind of extensively inbred population, I'd look in another direction.
  30. armorshell

    armorshell Moderator Emeritus

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    The accessory innervation to the lower molars you're probably thinking about comes from the cervical plexus, and is supposedly very rare/may not actually exist.
  31. aphistis

    aphistis Moderator Emeritus

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    This is exactly what I do. If you can stick the needle into the PDL space in a location, you don't need to inject there. I don't give the PDL injection until I find the spot where they react to the needle.
    Nope. The spinal accessory and hypoglossal nerves are both motor-only. The most likely culprits, particularly for posterior teeth, are aberrant branches of the ipsilateral trigeminal nerve that exited the nerve trunk proximal to your injection site. This is a highly plausible explanation for why the Gow-Gates injection enjoys such a consistently high success rate; by blocking the mandibular nerve immediately after it exits the cranial vault, you pre-empt any potential problems with the nerve's variable distal anatomy. As you move anteriorly, innervation from the contralateral nerve becomes progressively more common.

    Whoever told you the cervical plexus is "very rare/may not actually exist" misinformed you egregiously. The cervical plexus is a well-described, universally present anatomic structure:
    The cervical plexus only supplies sensation to a small portion of the face, however (the skin overlying the angle of the mandible). It does not supply any fibers to the oral cavity.
  32. armorshell

    armorshell Moderator Emeritus

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    Owned. I meant that accessory sensory innervation to mandibular molars from the cervical plexus is very rare/may not exist. My apologies.

    There's an anesthesia professor at Pacific who believes that in some circumstances (in his experience), local blocks to some branches arising from the cervical plexus have been successful in managing patients who "could not get numb" in the lower molar area. Completely anecdotal, hence, "may not exist" though there is *some* research (on cats) on the topic: Arch Oral Biol. 1993 Jul;38(7):619-22.
    Last edited: Jun 6, 2009
  33. AirborneDentist

    AirborneDentist

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    Ok...I haven't read all the replies here...way too many...I have taken out almost 4000 teeth...here is my input..

    Make sure you give your typical IA block...wait until anesthesia sets in..then also give a long buccal...and a local inflitration apical to the mandibular tooth you are removing...

    I elevate for about 10 seconds...If I don't see any movement...I am laying a flap and sectioning...simple as that..

    3rds are generally easier than erupted non-thirds...

    have a bite block in on all mandibular extractions
    have your assistant make a fist and place pressure right on the joint/mandibular regions...their jaw should not move while are you are working

    I ONLY use 2% Lido with 1:100k epi...no exceptions...never had a problem...may have to give multiple injections...but is ALWAYS does the job...no ligamental injections either..

    Hope that helps...
  34. DS1guy

    DS1guy

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    The first thing I do is explain to the patient the difference between PRESSURE and PAIN. Actually show them, (I push on their shoulder or squeeze their hand hard and explain that this is pressure.) They are going to feel a tremendous amount of pressure, especially when there is no bone loss. Tell the patient if they feel anything "sharp"/ painful, you can help take that away with more anesthesia. Pressure is OK (there is nothing you can do about it.) As long as the patient understands this difference, I find they do a lot better. As for anesthesia, I find that you can never use too much anesthetic. They just feel the pressure and get scared. For anesthesia, I start with my conventional blocks (mandibular) and infiltration (maxillary.) I use a whole carp for whatever my initial injection is. Then I load another and infiltrate around whatever tooth I'm taking out (PDL, pulpal, etc.) Make sure the tissue is really blanched around the whole tooth. You don't need a special PDL injection gun, just use you're regular needle, but make sure you do it after the block has taken effect because they hurt like hell. Then I walk around the tooth with periosteal elevator and ask the patient if they feel pressure or a "bee sting" feeling. During the procedure, warn them and let them know they are about to feel a ton of pressure. Basically just talk them through it and it'll help with any of their anxiety.
  35. 1992Corolla

    1992Corolla CheerioKing

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    There is an endo faculty at temple who has done extensive research on cervical plexus innervation. Having attended one of his lunch n learns I am now a master at the process.:cool: It is pretty much a needle inserted into the vestibule below the tooth you're trying to extract/endo/etc. Local infiltration of the lateral border of the jaw to get the nerve.

    My extraction steps (I have done about 100 ext in dental school so far FYI)

    1) Make sure the patient knows the difference between *sharp pain and *pressure. Squeeze thier shoulder like someone mentioned or poke the *numb side and then poke the unnumb side. They should be able to tell the difference.

    2) While elevating make sure that you tell them "LOTS of pressure during this step. It will feel weird because it is not normal. BUT IT should NOT be sharp pain" Most of them grin and bear it

    3) If they continue with sharp pain. Local infiltration (blanch the hell out of the tissue and a PDL. If they wince during either, then you know it was sharp - otherwise they are just feeling pressure)

    4) Still in pain? Go deeper in the vestibule on the buccal down the lateral border of the mandible (like a max infiltration) nd get that elusive cerv plexus monster. Also inject on the lingual.

    5) Then finesse that tooth out with "deliberate controlled force" what I like to say.

    The thing I have learned in school is that sometimes dental students pansy around too much turning a 5 min procedure into a 45 minute torture session for the patient. Just pull the darn tooth out and send the patient packing.

    This is my experiance and I rarely go over 4 carps of lidocaine for one lower molar tooth. But who cares right? 2.5 or 6 carps I still haven't reached my max dose on a 180 lb healthy man...
  36. aphistis

    aphistis Moderator Emeritus

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    Your comment about spending too long on the procedure is a bullseye. It's frequently because the operator isn't comfortable yet doing the procedure. As your comfort with oral surgery grows, the time you spend on each portion of an extraction procedure will shrink dramatically.

    The importance of good anesthetic technique comes into play when you're doing a lot of dentoalveolar surgery in one appointment. You've got a finite amount of local anesthetic you can inject, so you want to cover as much acreage with it as possible.
  37. MALOKINMARTIN

    MALOKINMARTIN Member

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    Septocaine has a higher rate of permanent paresthesia than Lid. Better to do an injection the right way than just use the big guns cause you can

    p.s. 4 carps is a crazy ammount of lid for extraction imho
  38. aphistis

    aphistis Moderator Emeritus

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    That's like arguing that you're more likely to die from a lightning strike than you are from being hit by a meteor. When you get close enough to zero, the risk differential becomes insignificant.

    P.S. Don't worry, at some point it'll happen to you too. ;)
  39. 1992Corolla

    1992Corolla CheerioKing

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    There is a lot of current lit about septocaine NOT causing parasthesia. I know a few GP and specialists who use it for everything.

    Our school faculty will not let us do blocks with it because some of the lit says parasthesia, but 4 carps of lidocaine is sometimes needed for 3 mand ext on some patients. I find that the ext can be performed much quicker if the patient is ABSOLUTELY numb before the pressure of elevators and forceps is used.

    Anxiety is decreased if no sharp real pain is felt and the patient relaxes and lets you do your job. Do I use 4 on EVERY pt.? NO! But sometimes it is needed and if the patient is healthy and they can tolerate more carps and they are still not numb....inject away.
  40. toothy2112

    toothy2112

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    The Dr. I work for currently uses it for everything. I have seen him use 3-4 carps at a time and no one has had any problems since I have been there.
    ;)
  41. Sweeti8286

    Sweeti8286 Senior Member

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    I know most of the things have already been mentioned...more local infiltration, septo, PDL, accessory innervation, etc. Sometimes you simply just can't numb the patient all the way due to the extensive caries / infection that mess the whole pH environment, which I am suspecting since the patient is sitting in your chair to get that tooth extracted. In that case, I usually send them home with antibiotics and some pain meds....they may hate you for it, but I would rather not put them through hell.

    I have done it a few times where even if the patient reports numbness to the midline, I still do local infiltration in the interdental papilla because I also sometimes notice when I place the elevator to elevate, the patient make this face and report pain. Then I give them local in the interdental papilla area and they usually quit the faces. Could be the psycological thing on their part...cuz I usually loosen the gingival cuff before I elevate and they don't make any faces at me....it's only when I elevate.

    I know this may sound harsh, but sometimes you just have to deal with the faces people make during the extraction....no one likes to have a tooth ripped out from their skull. If you stop every time they make a face, it'll take forever to get that thing out.
  42. DrJeff

    DrJeff Senior Member Moderator

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    :xf:

    There are just some cases when volume (even with correct technique) is your only friend!:eek:
  43. DrJeff

    DrJeff Senior Member Moderator

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    Good points. Anyone who has practiced long enough that administers local anesthesia regularly WILL encounter a patient that they just can't get 100% (heck sometimes even 50%) numb.

    The key to these, is even though inside, you're likely frustrated beyond belief (and so is the patient), to keep calm and mentally have a plan in place.

    In rare situations like that, without the ability to administer some IV meds, the best thing to do may be either a) get them to the oral surgeon ASAP who may very well be able to use some meds that legally your not allowed to or b) send them home with ABX + some GOOD pain meds and then call them later and either reappoint in a few days or refer to the OMFS crew

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