Inferior Alveolar Nerve Blocks

[Dane07MD]

I'm sure many of us groan when a patient comes in with dental pain and just awful dentition in need of an actual dentist. Usually these people get my best attempt at an inferior alveolar nerve block (if it's a lower tooth), some antibiotics, a handful of hydrocodone and discharged (+/- I&D if called for). I'd venture to guess many of you are in the same boat.

I just returned from the dentist to have a cavity filled and his inferior alveolar nerve block was wonderful. In fact, it turned nearly my entire ipsilateral lip numb, along with tongue and the anterior portion of my chin on that side. Seems like a phenomenal block for children (and adults obviously) with lip or chin lacs that are far enough up the chin (doesn't seem to anesthetize the usual chin laceration spot though). I'm sure many of the seasoned practitioners are already aware of this, but just wanted to see who uses this block on a regular basis and in what other convenient settings. Also have read that one can use the hockey stick (small parts) probe on ultrasound to even assist with nerve ID with this procedure. Anyone do this?

Some quick reading shows that 25 gauge needle and 3.5mL of bupivacaine is ideal. Sadly, looks like there's about a 15-20% failure rate. Anyone out there have suggestions to help maximize success?

I need to find some interns to practice on.

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[Birdstrike]

I'm sure many of us groan when a patient comes in with dental pain and just awful dentition in need of an actual dentist. Usually these people get my best attempt at an inferior alveolar nerve block (if it's a lower tooth), some antibiotics, a handful of hydrocodone and discharged (+/- I&D if called for). I'd venture to guess many of you are in the same boat.

I just returned from the dentist to have a cavity filled and his inferior alveolar nerve block was wonderful. In fact, it turned nearly my entire ipsilateral lip numb, along with tongue and the anterior portion of my chin on that side. Seems like a phenomenal block for children (and adults obviously) with lip or chin lacs that are far enough up the chin (doesn't seem to anesthetize the usual chin laceration spot though). I'm sure many of the seasoned practitioners are already aware of this, but just wanted to see who uses this block on a regular basis and in what other convenient settings. Also have read that one can use the hockey stick (small parts) probe on ultrasound to even assist with nerve ID with this procedure. Anyone do this?

5 gauge needle and 3.5mL of bupivacaine is ideal. Sadly, looks like there's about a 15-20% failure rate. Anyone out there have suggestions to help maximize success?

I need to find some interns to practice on.

Acute dental pain = one of these easiest chief complaints you'll ever see. No groans here.

Super easy block. Bupi, dental needle, 3-4 cc of 0.25% is fine. Dental syringe makes easier, but any 5-10 cc syringe with a 25 or 27 gauge needle is fine. Wait 10-15 min. Ultrasound would likely be more trouble than worth. Kinda like using ultrasound to do a digital nerve block. Getting ridiculous at that point. You're never going to see the nerve. Don't need to. Just inject lots of bupi and don't poke the carotid.

 

[Doctor Bob]

Inferior alveolar block is one of my favorite blocks. It's diagnostic as well as therapeutic.

If you come in complaining of the worst dental pain anyone could ever have, have a normal dental exam, and balk when I offer the IA block, then you go home with ibuprofen.
Even with a normal exam, if you say the pain is so bad that you would gladly take the block, then you go home with norco (post block).

 

[RustedFox]

Its funny that this should come up. One of my NP's had her first "successful IA block" just yesterday, and was rather proud of it. Good on her.

Dad was(is) a dentist. Key to this is going more superior than you think.

EDIT: Take a look at the patient's teeth, specifically their molars... if they look like they're a "tooth grinder" (and I am one)... then they're going to need a bit more than the usual amount of anesthesia.

 

[Birdstrike]

Its funny that this should come up. One of my NP's had her first "successful IA block" just yesterday, and was rather proud of it. Good on her.

Dad was(is) a dentist. Key to this is going more superior than you think.

EDIT: Take a look at the patient's teeth, specifically their molars... if they look like they're a "tooth grinder" (and I am one)... then they're going to need a bit more than the usual amount of anesthesia.

Most shameless way to plant seed of "RustedFox is gonna need some dilaudid with that, too," as I've ever seen.

 

[Arcan57]

We're iffy on availability of the long acting -caines so I don't do a lot of blocks for dental pain but I highly recommend that all the students and early residents get very comfortable with the various facial blocks. Stitching together cosmetically sensitive tissue is so much easier when you're not dealing with distortion from local. It's also important to get a feel for what the blocks don't numb so you're not in the middle of a complex lip lac when you realize that you should have just started with bilateral infraorbital blocks.

Off topic but following BS's lead, but I once had a drug addict/recurrent shoulder dislocator that was hitting me up for a post-reduction narc script after 30mg of etomidate while the reduction was still ongoing. That was a man that knew his craft.

 

[RustedFox]

Most shameless way to plant seed of "RustedFox is gonna need some dilaudid with that, too," as I've ever seen.

Not sure if you're trollin' me or if its a gag, but...

....

I have never had any IV opiate other than fentanyl for my conscious sedation/colonoscopy.

I have never had a PO opiate. Period.

As the son of a dentist, I really do mean "you're going to need more than the usual" in terms of volume/nerve block. That is all. It is well-known in the dentist-sphere that those with flat-topped-(ground-down)-teeth are going to need more analgesia because of the grind-effect.

 

[suckstobeme]

Use this block all the time. I even give it to nurses who have dental pain if we have a little extra bupivicaine lying around.

Pt's who are actaully in pain and not just seeking love it. Those who refuse get motrin.

The only tip I have is that I go in from the contralateral side just above the canine on the contralateral side and aim for the inside of the mandible. Once I actually hit bone, I straighten the needle out so I'm no longer crossing the midline and I advance a little bit while aspirating; inject slowly as you withdraw.

There are a couple things you can do to increase success.
1) Use a greater volume, like 5cc
2) Do a buccal block as well as some of the innervation of the lower teeth is from the buccal nerve; I only really do a buccal block if I'm doing a dental procedure, not just for pain relief

Many dental syringes use 2% lidocaine with epi instead of bupivicaine. I've had it last 2-3 hrs, which is not as good as bupivicaine, but it's enough for people to get to sleep.

It's also "Regional Anesthesia: Trigeminal Nerve Block- Any Branch"; I think it's like 2 RVUs

 

[Birdstrike]

Not sure if you're trollin' me or if its a gag, but...

....

I have never had any IV opiate other than fentanyl for my conscious sedation/colonoscopy.

I have never had a PO opiate. Period.

As the son of a dentist, I really do mean "you're going to need more than the usual" in terms of volume/nerve block. That is all. It is well-known in the dentist-sphere that those with flat-topped-(ground-down)-teeth are going to need more analgesia because of the grind-effect.

Just messin wicha

 

[d2305]

Dentists use new synthetic "caines" and the dental syringe is easier to manipulate. A dental chair makes it easier too.

 

[RustedFox]

Just messin wicha

I dig. Sorry for being hypersensitive. I've had oh-too-many Narc-Zombies come thru on my shifts these days. There's one in particular that is seriously there every day. Every day. New complaint. New gambit for the dilaudid. He's gotten hip to the game that we have zero full-time docs (I'm the last one, and I'm leaving my present gig) and we're swimming with locums that have never seen his/her face before.

 

[Birdstrike]

I dig. Sorry for being hypersensitive. I've had oh-too-many Narc-Zombies come thru on my shifts these days. There's one in particular that is seriously there every day. Every day. New complaint. New gambit for the dilaudid. He's gotten hip to the game that we have zero full-time docs (I'm the last one, and I'm leaving my present gig) and we're swimming with locums that have never seen his/her face before.

He's gotcha, man. He's gotcha. Lol





(Edit: Just messin' wicha. Again.)

 

[Groove]

I do them if I really really sorry for the pt. They don't last that long as most of us are going to have to hunt for anything longer acting than marcaine. I don't do them nearly as much anymore because it slows me down. That being said, one of the few hugs I've gotten from a pt was after I performed one and they jumped up and grabbed me in a hug, weeping tears of joy. It felt like one of those scenes out of Star Trek V with Sybok "Share your pain with me and gain strength from the sharing....RELEASE YOUR PAIN! RELEASE IT!" It was really weird. Maybe I don't do them as much anymore because I was so freaked out...

 

[Tiger26]

Dental blocks are my favorite thing to do in emergency medicine. They're the nursemaid's elbow of the adult, in the sense that that provide instant gratification for patient and physician, which is unusual in our field.

I do inferior alveolar blocks most commonly. One thing that can help is to flap their gums around a little before the initial poke. Google "Kip Benko dental blocks" for a pdf--he teaches the ACEP dental block workshop.

 

[Saddleshoes]

The only tip I have is that I go in from the contralateral side just above the canine on the contralateral side and aim for the inside of the mandible. Once I actually hit bone, I straighten the needle out so I'm no longer crossing the midline and I advance a little bit while aspirating; inject slowly as you withdraw.

As a hospital attending dentist that makes my living training general practice dental residents, The IA block is my bread an butter. Suckstobeme gives great advice here!!!!
I would suggest to use the premolars on the contralateral side. One of the common problems is not placing the tip of the needle laterally enough due to the flair of the mandible.

 

[RustedFox]

As a hospital attending dentist that makes my living training general practice dental residents, The IA block is my bread an butter. Suckstobeme gives great advice here!!!!
I would suggest to use the premolars on the contralateral side. One of the common problems is not placing the tip of the needle laterally enough due to the flair of the mandible.

Explain more about needletip-lateral, please.

 

[EDMD4LIFE]

Dental blocks are my favorite thing to do in emergency medicine. They're the nursemaid's elbow of the adult, in the sense that that provide instant gratification for patient and physician, which is unusual in our field...

I agree. I love to do dental blocks. And I can get one done in less time than it takes to write out a Percocet script
I could do dental blocks all day....but then that would pretty much make me a dentist :/

...That being said, one of the few hugs I've gotten from a pt was after I performed one and they jumped up and grabbed me in a hug, weeping tears of joy. It felt like one of those scenes out of Star Trek V with Sybok "Share your pain with me and gain strength from the sharing....RELEASE YOUR PAIN! RELEASE IT!" It was really weird. Maybe I don't do them as much anymore because I was so freaked out...

My most satisfied customers are 1) true dental pain s/p dental block and 2) fecal impaction s/p disimpaction.

 

[Saddleshoes]

Explain more about needletip-lateral, please.

To really learn IA blocks well, get a hold of a disarticulated mandible from a study skeleton.

Take a look at the general shape of the mandible. Take special note of the foramen where the inferior alveolar nerve enters the mandible. You will notice the mandible seems to "bend" away from the midline at that point.

To place the needle tip "around behind" that bend is the trick. One way to skirt around the bend is to use the premolars on the contralateral side as a guide post. You can also physically bend the needle.

Good Luck with it!

 

[doctorFred]

people usually seem disappointed with the offering, as if they were expecting me to pull the tooth for them. sometimes i'm tempted to go into the room with the giant bolt cutters and say "ok, let's do this."

 

[BCMoon]

OP: I think what you are describing is technically a Gow-gates block, google it, YouTube it, it's great.

 

[RustedFox]

Does anyone want to wax technical on the superior alveolar nerve block technique(s) and nuances ?