Articaine Poll

[Swamp Yankee]

to the OMFS residents and senior dental students:

an interesting clinical situation has come about in our school relating to the use of articaine. with a recent shift in administrative powers, the anesthetic has been banned from use (along with all other 4% juices) in the main clinic; OMFS continues to use it behind their closed doors, despite being viewed by the rest of the school as some sort of black-market contraband (they do however stand behind it's "contraindication" for IA). [On a side note, the powers-that-be have put a cap on the amount of anesthetic dispensed (2 cartridges); anything more requires instructor permission, and another signature]. In a healthcare world that's becoming more and more "evidence based," it seems like a hypocritical slap in the face to the students not to justify such radical shifts in protocal with... well, what else... EVIDENCE. I've reviewed many of the relevant studies and I'm familiar with both sides of the Articaine argument. There's no denying that the literature is muddled, and there's some critical flaws to each side. I was wondering what everyone's experience has been like at residency with respect to local anesthetics. I know there's some variation; for instance, I spent time at one OMFS program that didn't allow the use of Marcaine because of the "threat of NEUROTOXICITY". It just seems like there's so much dogma out there and the research is filled with so many confounding variables and reporting biases. Anybody got any solid ground to stand on, or should we just continue to practice the way the lawyers dictate...

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[rrc]

I dont use Articaine because I have read the literature and heard the horror stories. Is it true? Who knows. But it's just a personal choice. Besides, lidocaine has always worked fine for me from an intermediate acting local standpoint.

The bigger problem is that the FDA has put a hold on Marcaine because it has changed suppliers and it is not yet approved for distribution. There is another bupivicaine called Sensorcaine but I have not been able to find much information on it.

http://www.kodak.com/global/en/health/dental/documentation/film/marcaineQandA.pdf

 

[jiggapigga]

i used articaine in dental school all the time , for everything..it works like a charm. In OMS, i use articaine for the mxilla usually, and if things don't get numb, i pull out the articaine where ever i am.

 

[DcS]

i used articaine in dental school all the time , for everything..it works like a charm. In OMS, i use articaine for the mxilla usually, and if things don't get numb, i pull out the articaine where ever i am.

Same here, I always felt the research was weak and have used it fine in school without any problems.

I think with proper injection protocol you can lower your risk of causing permanent parasthesia. As long as you are careful not to inject into the nerve sheath itself there shouldn't be a problem. Of couse if a pt is numb that's not possible to determine but you shouldn't have to go back in if they are anyways.

 

[OMFSCardsFan]

...and if things don't get numb, i pull out the articaine where ever i am.

Chances are if you would have grabbed another carpule of Lidocaine, you would have gotten the same result. I don't think Articaine works any better than Lidocaine. I had unlimited access to it at a community clinic, where I spent every Thursday my last semester doing only dentoalveolar procedures. My opinion is that it "magically" works for some people for a couple reasons:

1. The extra time needed to get and administer the Articaine gave the original Lidocaine time to distribute.

2. After "missing" a block, the person administering the Articaine pays more attention to landmarks, and he deposits the anesthetic more appropriately the second time.

In either of these situations, the person will jump on the Articaine wagon, praising it as the greatest local ever created. I don't know of a situation where the tissue perfusion of Lidocaine is ineffective. If you put the local by the nerve, it's going to get numb. The maxilla is fool-proof easy to anesthetize regardless.

The only other local anesthetics that I use are Marcaine, when I want a longer-lasting anesthesia, and Carbocaine. I use Carbocaine in some cardiovascular patients (I also think the Epi contraindication is blown out of proportion to a large extent) and occasionally as an adjunct to Lidocaine in infections. Carbocaine has a lower pKa, which allows it to work better in an acidic environment, i.e. infections. Combine it with some Lidocaine with epi, and you're getting some vasoconstriction effect as well.

Sorry to get on the soapbox on that...

 

[drhobie7]

(I also think the Epi contraindication is blown out of proportion to a large extent)

I agree. Lido w/epi provides longer lasting pain control than plain, which is important for controlling endogenous epi release caused by pain during a procedure. The adrenals will release way more epi than is present in a couple cartridges of lido. It's kind of ironic that some people will avoid using lido w/epi on cardiac risk pts and then fail to get adequate anesthesia, thereby causing them significant stress.

 

[Periogod]

If I were you I would be less mad about not getting to use Articaine and more mad about only getting 2 carpels of Lido. There are other anesthetics that work great (like my favorites Lido and Citanest Plain-another 4%) but for those 4 hour crown preps I don't know if 2 carpels are going to do it, and it seems kind of demeaning to have to go ask an instructor for another LA carpel.

 

[DcS]

It's kind of ironic that some people will avoid using lido w/epi on cardiac risk pts and then fail to get adequate anesthesia, thereby causing them significant stress.

Yeah but the body will titer natural epi, yeah it may be introduced it in large amounts during stress but epi from local is a direct shot into the circ system with the heart in close proximity. I have no way to quantify this but think this is what makes that warning 'not so ironic after all'. I have an instructor who had a patient have systemic rxns from epi injection during local and also from placing a cord w/ racemic epi.

I guess it's the type of thing you never think will happen to you, but if it does you never do it again.

 

[drhobie7]

Yeah but the body will titer natural epi, yeah it may be introduced it in large amounts during stress but epi from local is a direct shot into the circ system with the heart in close proximity. I have no way to quantify this but think this is what makes that warning 'not so ironic after all'. I have an instructor who had a patient have systemic rxns from epi injection during local and also from placing a cord w/ racemic epi.

I guess it's the type of thing you never think will happen to you, but if it does you never do it again.

I'm not sure I understand what you mean about the body titrating epi. I guess you mean the release is proportional to the stimulus? That makes sense. Dental pain can be a pretty strong stimulus, especially for an anxious patient.

As for epi from local anesthetic being a direct shot into the circ system. I think endogenous epi is a direct shot as well. You know when you're about to get into a bar fight in the Mexican barrio and your heart is pounding in your chest cause the vatos are gonna kick your ass... 😱 ...that's epi pumped right into your blood stream by the adrenals.

Also worth noting, it could be difficult to determine if that patient's reaction was from the epi in the local or their own endogenous epi released as a result of the stress of receiving an injection. (I have heard that racemic epi cord can carry a sizeable amount.)

 

[toofache32]

I don't think I've ever used Articaine, even though it's in our clinic. Lidocaine & Marcaine have never failed me and are safe, so I've never had a need for anything else.

 

[DcS]

I'm not sure I understand what you mean about the body titrating epi. I guess you mean the release is proportional to the stimulus? That makes sense. Dental pain can be a pretty strong stimulus, especially for an anxious patient.

As for epi from local anesthetic being a direct shot into the circ system. I think endogenous epi is a direct shot as well. You know when you're about to get into a bar fight in the Mexican barrio and your heart is pounding in your chest cause the vatos are gonna kick your ass... 😱 ...that's epi pumped right into your blood stream by the adrenals.

Also worth noting, it could be difficult to determine if that patient's reaction was from the epi in the local or their own endogenous epi released as a result of the stress of receiving an injection. (I have heard that racemic epi cord can carry a sizeable amount.)

All good points, I was moreso posing the question of which is more stimulating to the heart. I'd be curious if anyone could find a definitive answer.

 

[ItsGavinC]

i used articaine in dental school all the time , for everything..it works like a charm.

I use it all the time as well.

 

[Swamp Yankee]

Chances are if you would have grabbed another carpule of Lidocaine, you would have gotten the same result. I don't think Articaine works any better than Lidocaine. I had unlimited access to it at a community clinic, where I spent every Thursday my last semester doing only dentoalveolar procedures. My opinion is that it "magically" works for some people for a couple reasons:

1. The extra time needed to get and administer the Articaine gave the original Lidocaine time to distribute.

2. After "missing" a block, the person administering the Articaine pays more attention to landmarks, and he deposits the anesthetic more appropriately the second time.

In either of these situations, the person will jump on the Articaine wagon, praising it as the greatest local ever created. I don't know of a situation where the tissue perfusion of Lidocaine is ineffective. If you put the local by the nerve, it's going to get numb. The maxilla is fool-proof easy to anesthetize regardless.

The only other local anesthetics that I use are Marcaine, when I want a longer-lasting anesthesia, and Carbocaine. I use Carbocaine in some cardiovascular patients (I also think the Epi contraindication is blown out of proportion to a large extent) and occasionally as an adjunct to Lidocaine in infections. Carbocaine has a lower pKa, which allows it to work better in an acidic environment, i.e. infections. Combine it with some Lidocaine with epi, and you're getting some vasoconstriction effect as well.

Sorry to get on the soapbox on that...

wise man... i couldn't agree more.
i guess for me the issue is not whether or not it's a superior anesthetic... nothing is, just get the sleepy juice on the nerve and woo-hoo, it goes numb -- randomized clinical trials show that. i'm just bent out of shape over the complete bastardization of "evidence-based-medicine." it's a bold statement to pull a drug from clinic, in my eyes, you better have a reason. as a matter of fact, if students are getting "success" with it for all those reasons that you mentioned CARDSFAN, than what the hell, let 'em use it if that's what it takes... a placebo effect is a REAL effect. stupid dental school.

 

[gansey]

i used articaine in dental school all the time , for everything..it works like a charm. In OMS, i use articaine for the mxilla usually, and if things don't get numb, i pull out the articaine where ever i am.

is it better than septocaine?

 

[drhobie7]

is it better than septocaine?

septocaine is the trade/brand name for articaine

 

[adamlc18]

Same here, I always felt the research was weak and have used it fine in school without any problems.

I think with proper injection protocol you can lower your risk of causing permanent parasthesia. As long as you are careful not to inject into the nerve sheath itself there shouldn't be a problem. Of couse if a pt is numb that's not possible to determine but you shouldn't have to go back in if they are anyways.

DcS,

Can you only get it in the endo clinic here? I wanted to get some artocaine for one of my patients because his tongue is so big neither I nor my attending could get back there for a block. Someone suggested doing an intraligamentary with artocaine but I don't know where to get it.

 

[OMFSCardsFan]

DcS,

Can you only get it in the endo clinic here? I wanted to get some artocaine for one of my patients because his tongue is so big neither I nor my attending could get back there for a block. Someone suggested doing an intraligamentary with artocaine but I don't know where to get it.

Did you try the Gow-Gates or the Akinosi (closed-mouth) technique--that ought to take the tongue out of the equation? I'm not a big fan of the intraligamentary injection. You could also try sticking him in the tongue--that ought to get him thinking about helping you out a little.

 

[OMFSCardsFan]

is it better than septocaine?

Wow...

 

[OMFSCardsFan]

...a placebo effect is a REAL effect.

I agree with that 100%. In dental school, if I was having trouble with a patient claiming not to be numb when it was pretty obvious that they were, I'd tell them, "OK, I'm going to go get a carpule of the really expensive stuff, the 2% Lidocaine with 1:100,000 epinephrine. Now, we can't use this all the time because it's so expensive, but it never fails to do the trick." Guaranteed success after the next carpule...

 

[DcS]

DcS,

Can you only get it in the endo clinic here? I wanted to get some artocaine for one of my patients because his tongue is so big neither I nor my attending could get back there for a block. Someone suggested doing an intraligamentary with artocaine but I don't know where to get it.

Go down to Oral Sx they have it there.

 

[tx oms]

Why reinvent the wheel? What is wrong with lidocaine? Why do some people need to look for something "better" when lidocaine works?

 

[wayoutwest]

I use it sometimes also, but I agree that almost all the time Lido is sufficient. So if Lido is cheaper (?) and safer, I see little reason to use Septo very often at all. The question, I guess, is if it is really safer or not. I don't see that answered with solid evidence. I hear that in Europe just about everyone uses Septo. Interesting, eh?