Local anesthetics solution.

[toothie]

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I had an amalgam filling done on #5 -disto occlusal and #2 occlusal pit.
after the procedure , the right side of the face looked red and swollen , but i did not say anything as i presumed it was due to the local anesthetic solution.
it took 10 hours for the anesthesia to start wearing off , the right side of the face was completely swollen and still is 2 days after the procedure and there is a bruise at the corner of my lip where the dentist was holding the cheek and shaking it while injecting.
the following day when i spoke to her she said that the swelling was a normal response of the body .
and that 2 carpules of articaine were injected.

my questions are:

1. why are 2 carpules being injected in areas adjacent to each other .
is 1 carpule required for each tooth ?
the area anesthetised was the area supplied by the inferior orbital nerve.
but when i questioned if the inferior orbital nerve block was given , the answer i got was , this is the way we give anesthesia.
as per my knowledge 0.9-1.2 ml is required for infraorbital block and 0.6 ml is given for local infiltration.thus my doubt.

2. why is the cheek shaken during injecting solution.

3. how long does it usually take for anesthesia with articaine to wear off.
i have experience with lidocaine and as they both belong to the amide group i was wondering whats the difference between lidocaine and articaine .


4.is it a normal body response to have edema.!!! (according to my knowledge it isnt..)

5.is it possible that a person who reacts normally to lidocaine hyper reacts to articaine.

thnak you for your help in advance..!!!

 

[12YearOldKid]

"as per your knowledge"... Some patients know just enough to be a giant pain in the butt.

1. Sometimes you need two carpules
2. Shaking the cheek is a distraction technique to minimze the pain of injection.
3. It depends on how close to the nerve you get; the longer you are numb the better the aim of the dentist
4. Lots of things could have happened here; I'm sure you're fine.
5. Anything is possible; but many of those same things are not PROBABLE. This is one of those cases.

 

[toothie]

i am dentist ..!! and patients are not alwasy pains in the butt!!!!
i am joining an advanced standing programme for international trained dentists this year.

 

[ItsGavinC]

i am joining an advanced standing programme for international trained dentists this year.

If that's the case, then I'm a bit worried that you don't know the answer to simple questions such as "is 1 carpule required for each tooth?"

No offense meant, but it seems you should know the answer to these questions. Do dentists not use LA where you practice?

 

[toothie]

"as per your knowledge"... Some patients know just enough to be a giant pain in the butt.

1. Sometimes you need two carpules
2. Shaking the cheek is a distraction technique to minimze the pain of injection.
3. It depends on how close to the nerve you get; the longer you are numb the better the aim of the dentist
4. Lots of things could have happened here; I'm sure you're fine.
5. Anything is possible; but many of those same things are not PROBABLE. This is one of those cases.

1.i agree u need 2 carpules SOMETIME but do u start with giving 2 carpules in a close vicinity..
2.shaking the cheek is a good distrction technique but shake it soo much that it BRUISES THE PATIENT..!!!!
3.the longer ure numb..... 10 hours for a 30 min procedure..!!
4.i am fine except for the swelling , pain , trismus(even after 2 days..) and the dentist telling me that its a normal body reaction..!!!!
this is not the first time that ive taken local anesthesia . ive had 3 difficult (horizontal )disimpactions and had no problems..!!!
and never im my experiance have i ever bruised a patient or given excess anesthetic solution if not required and neither in my 3 yrs of practice has a patient ever reported back with swelling due to UNKNOWN CAUSES..!!!

 

[toothie]

If that's the case, then I'm a bit worried that you don't know the answer to simple questions such as "is 1 carpule required for each tooth?"

No offense meant, but it seems you should know the answer to these questions. Do dentists not use LA where you practice?

u mean to say ure giving 1 carpule i.e. 1.8 ml for each tooth even when the recommended dose for a nerve block is 0.9-1.2 ml.!!!!!!!!
and for infiltration 0.6ml..!!!!!
where are the recommendations for giving 1.8 ml when u can acheive the same effect with half the amount..!!

 

[cusp of carabelli]

u mean to say ure giving 1 carpule i.e. 1.8 ml for each tooth even when the recommended dose for a nerve block is 0.9-1.2 ml.!!!!!!!!
and for infiltration 0.6ml..!!!!!
where are the recommendations for giving 1.8 ml when u can acheive the same effect with half the amount..!!

well.....you should be giving an infiltration on the buccal and palatal....and if each is supposed to be .6 ml, that's almost a full carpule just for one tooth. besides...you should know that #2 and #5 are far enough away from each other that there is a chance of cross-innervation from other nerves when talking about the premolar....so in this case it is better to do 2 carpules.

 

[lnn2]

i am dentist ..!!

if you're a dentist then you should know the answers to those simple questions. But since you asked, I'll humor you!

1.i agree u need 2 carpules SOMETIME but do u start with giving 2 carpules in a close vicinity..
2.shaking the cheek is a good distrction technique but shake it soo much that it BRUISES THE PATIENT..!!!!
3.the longer ure numb..... 10 hours for a 30 min procedure..!!
4.i am fine except for the swelling , pain , trismus(even after 2 days..) and the dentist telling me that its a normal body reaction..!!!!
this is not the first time that ive taken local anesthesia . ive had 3 difficult (horizontal )disimpactions and had no problems..!!!
and never im my experiance have i ever bruised a patient or given excess anesthetic solution if not required and neither in my 3 yrs of practice has a patient ever reported back with swelling due to UNKNOWN CAUSES..!!!

1. #2 and #5 are not "in a close vicinity" You need 2 different infiltrations, one for each tooth (unless you're giving a PSA block for #2.) I would give 1/2 carpule for each tooth, full carpule prn.

2. shaking the cheek is not necessary imo. It's more important to stretch the tissue (vestibule) enough and giving a slow injection so that it minimizes the discomfort during the infiltration.

3. You were numb for 10hrs??? Anesthesia is obtained w/in 3minutes for articaine. The pulpal analgesia lasts around 1.5hrs for a carpule. I wouldn't use articaine for maxillary infiltration though.

4. Although it's an expected complication from anesthesia infiltration/block, it's not "a normal body response to have edema." It's not uncommon to have hematoma and other complications/reactions. Did you have a PSA block?

u mean to say ure giving 1 carpule i.e. 1.8 ml for each tooth even when the recommended dose for a nerve block is 0.9-1.2 ml.!!!!!!!!
and for infiltration 0.6ml..!!!!!
where are the recommendations for giving 1.8 ml when u can acheive the same effect with half the amount..!!

There's no such thing as a recommended dose for a nerve block or infiltration, imo, just the max dosage of anesthetic for a patient.
Giving 1/2 carpule yields the same effect as a full carpule but a full carpule lasts longer!

 

[toofache32]

u mean to say ure giving 1 carpule i.e. 1.8 ml for each tooth even when the recommended dose for a nerve block is 0.9-1.2 ml.!!!!!!!!
and for infiltration 0.6ml..!!!!!
where are the recommendations for giving 1.8 ml when u can acheive the same effect with half the amount..!!

I'm also amazed you're a "dentist" but don't know the answers and have never seen these issues. Even if you haven't been taught the shake-the-cheek method you should still be able to figure it out.

I don't think there is really a "recommended" dose. The dose to give is however much it takes to get you numb, below the level of toxicity!!!!!!!! 2 carpules is nothing, and I can't figure what your problem is with 2 carpules!!!!!! Or with punctuation!!!!!! Are you really making an issue between 1.2 and 1.8 ml of local????????

Many dentists (like me) simply start off with 2 carps right off the bat, then give more if needed (regardless of which local used).

Shaking the cheek doesn't bruise the patient....injecting fluid into a space where there is no space causes bruising. If you take daily aspirin or some herbal meds you can be more susceptible to this bruising also.

You say you were "numb" for 10 hours but I doubt it. Not numb enough for more work, but I'm sure you were still feeling the inflammation from the injection and the dental work.

No wonder they make international dentists go back to school here. I know that sounds mean, but that's just my observation.

 

[toothie]

if you're a dentist then you should know the answers to those simple questions. But since you asked, I'll humor you!


1. #2 and #5 are not "in a close vicinity" You need 2 different infiltrations, one for each tooth (unless you're giving a PSA block.) I would give 1/2 carpule for each tooth, full carpule prn.

2. shaking the cheek is not necessary imo. It's more important to stretch the tissue (vestibule) enough and giving a slow injection so that it minimizes the discomfort during the infiltration.

3. You were numb for 10hrs??? Anesthesia is obtained w/in 3minutes for articaine. The pulpal analgesia lasts around 1.5hrs for a carpule. I wouldn't use articaine for maxillary infiltration though.

4. Although it's an expected complication from anesthesia infiltration/block, it's not "a normal body response to have edema." It's not uncommon to have hematoma and other complications/reactions. Did you have a PSA block?


There's no such thing as a recommended dose for a nerve block or infiltration, imo, just the max dosage of anesthetic for a patient.
Giving 1/2 carpule yields the same effect as a full carpule but a full carpule lasts longer!

well i do know the answers but we ddint shake patients cheeks we just stretched them and gave a slow injection to minimise the pain.. we never bruised them while injecting , thus if this is how you practice here.. need to understand the laws of the land...
why i asked was because i know that anesthesia lasting for 10 hrs is not normal.and then i reported the same to the dentist her response was thats normal...
i dont have experaince with articaine , we only used lidocaine thus i voiced my concerns , theoretically lidocaine and articaine are similar except that anesthesia is more profound ,as i dont ahve any clinical experaince with articaine thus i asked when i didnt receive any convincing answers from my dentist.

i dont know what block she gave me cause i felt like she gave my an infra orbital block but when i asked her she said this is how we give it , she dint asnwer my question..
that is why im asking..!!

complications can occur .. but being honest with the patient is more important rather than giving some silly reason .. "that this is how the body responds.."
and to correct you PSA will not block 2 and 5 . it will block only 2 .thus even if one block is given one infiltration will be required unless u plan to give 2 blocks.
and this is after me telling her that i dont want anesthesia for a filling..!!!! its easier to bear the pain for 5 mins rather than bear 2 days of agony..

 

[toothie]

I'm also amazed you're a "dentist" but don't know the answers and have never seen these issues. Even if you haven't been taught the shake-the-cheek method you should still be able to figure it out.

well we havnt been taught the shake the cheek method but i did figure it out... but just wanted to confirm.

I don't think there is really a "recommended" dose. The dose to give is however much it takes to get you numb, below the level of toxicity!!!!!!!! 2 carpules is nothing, and I can't figure what your problem is with 2 carpules!!!!!! Or with punctuation!!!!!! Are you really making an issue between 1.2 and 1.8 ml of local????????

i am not making an issue ... just trying to figure out why give excess anesthetic solution when its not required....
esp when anesthesia lasts for 10 hrs..!!

Many dentists (like me) simply start off with 2 carps right off the bat, then give more if needed (regardless of which local used).

Shaking the cheek doesn't bruise the patient....injecting fluid into a space where there is no space causes bruising. If you take daily aspirin or some herbal meds you can be more susceptible to this bruising also.

i am not taking aspirin or any medication and what ure saying would be correct if had a hematoma in the vestibule but as its on the cheek im presuming it was because of shaking the cheek too hard..

You say you were "numb" for 10 hours but I doubt it. Not numb enough for more work, but I'm sure you were still feeling the inflammation from the injection and the dental work.

it took 10 hrs before soft tissue anesthesia even started wearing off....and you are no one to judge...i have no reason to make up stories.

No wonder they make international dentists go back to school here. I know that sounds mean, but that's just my observation.

it did
i just asked simple questions and all i recieved was hostility.

 

[DcS]

Don't have too much time to write a lengthy response but 2 carpules for 2 teeth is nowhere near excess. And in the close vicinity? You need two separate infiltrations for that, possibly some palatal etc.

 

[lnn2]

and to correct you PSA will not block 2 and 5 . it will block only 2 .thus even if one block is given one infiltration will be required unless u plan to give 2 blocks...

I know what's a PSA for! It doesn't anesthetize first molar completely. I didn't make it clear but thanks for the correction!

i dont know what block she gave me cause i felt like she gave my an infra orbital block but when i asked her she said this is how we give it , she dint asnwer my question..
that is why im asking..!!

If you don't know or unable to recognize the gigantic difference between an Infra orbital block and a PSA block (or infiltration) then you're not really a "dentist," which leads me to agree with toofache32.

BTW, there's an injection techniques for max and mand DVD that you might want to purchase. I have one. It's very helpful. Another distraction technique is to tell the patient, a gagger or a dental phobic, to lift up his/her leg a little bit and keep it there while you're taking an impression or giving an injection.

 

[toofache32]

...Another distraction technique is to tell the patient, a gagger or a dental phobic, to lift up his/her leg a little bit and keep it there while you're taking an impression or giving an injection.

Or just grab their lip in your fist and yank it out of the way, bury the needle and yell "POP GOES THE WEASEL!"

Works for me...

 

[lnn2]

Or just grab their lip in your fist and yank it out of the way, bury the needle and yell "POP GOES THE WEASEL!"

Works for me...

I would really love to try that!

 

[toofache32]

i just asked simple questions and all i recieved was hostility.

I now realize that my last comment sounded downright rude. Instead of editing it, I would rather leave it and just apologize. I'm sorry. But it still makes me wonder when I see questions like this here, then those posts over in the international forums. I'm sure some others here know what I'm talking about.

 

[toothie]

I know what's a PSA for! It doesn't anesthetize first molar completely. I didn't make it clear but thanks for the correction!


If you don't know or unable to recognize the gigantic difference between an Infra orbital block and a PSA block (or infiltration) then you're not really a "dentist," which leads me to agree with toofache32.

BTW, there's an injection techniques for max and mand DVD that you might want to purchase. I have one. It's very helpful. Another distraction technique is to tell the patient, a gagger or a dental phobic, to lift up his/her leg a little bit and keep it there while you're taking an impression or giving an injection.

i dont have any interest in continuing this discussion ,

i know the differnce between PSA and infro orbital blocks .
all i asked was answers to simple questions , i am not stupid that i dont know the difference between different blocks but clearly you can't even understand the questions that I wrote, but the point that i was trying to make was about the dentist not honestly answering my question, it is a matter of integrity and ethics. As for your ridiculous comment on experience....
i have enough experience and have the experience that you guys can only dream off . The number of procedures that we do far out number that you do in 4 years and 1 year of practice. so don't try to dazzle me with your knowledge ( or the clear lack of).

2) when u have ure face drawn to the normal side that u cant even talk properly for 10 hrs .. it will definitely make you think ... what happened...
there was no need to give anesthesia when i requested that i ddint need it , but just cause the dentist was more comfortable givnig it ..this is unethical.
This is probably what you are taught as CYA ( go look it up ina book if you don't know)

 

[UConn_SDM]

No wonder they make international dentists go back to school here. I know that sounds mean, but that's just my observation.

Before anyone gets their panties in a bunch I know there are terrific foreign trained dentists........that said today I had to listen to the same foreign trained resident (dental school in Peru and now doing a residency here) ask what is Tylenol 3 and what does IND mean. Not too impressed so far 😱 I'm more scared than anything for her as she will be thrown onto the burner pretty soon when she goes on call.

 

[ItsGavinC]

u mean to say ure giving 1 carpule i.e. 1.8 ml for each tooth even when the recommended dose for a nerve block is 0.9-1.2 ml.!!!!!!!!
and for infiltration 0.6ml..!!!!!
where are the recommendations for giving 1.8 ml when u can acheive the same effect with half the amount..!!

That's not what I'm saying at all. I was asking WHY you are asking a question that you already know (or should know!) the answer to?

 

[ItsGavinC]

all i asked was answers to simple questions , i am not stupid that i dont know the difference between different blocks but clearly you can't even understand the questions that I wrote, but the point that i was trying to make was about the dentist not honestly answering my question, it is a matter of integrity and ethics.

Nobody is saying that you're stupid, but your questions don't make a lot of sense, ESPECIALLY coming from a clinician. I'm not impressed with the vast number of procedures you do, based on the questions you're asking.

And, for the record, it is NOT unethical for the dentist to administer anestheia, even though you stated you didn't need it. They're the doctor, and administering is certainly within their scope of practice and judgement.

 

[DrJeff]

And, for the record, it is NOT unethical for the dentist to administer anestheia, even though you stated you didn't need it. They're the doctor, and administering is certainly within their scope of practice and judgement.

You might want to check yourself on this one Gavin. One of the malpractice seminiars given by my malpractice carrier addressed this exact issue. Where the Doc wants to administer anesthesia and the patient doesn't want it. The attorney said that if after you've explained to the patient what and why you want to do, and they don't want it, if you go against their wishes you're essentially committing battery 😱 I've even extracted 2 teeth(different patients) without anesthesia since they refused it (personally I think that thats more likely to be battery than administering anesthesia, but then again theres many things about the legal system that don't make sense)

I do find that in many instances if the patient doesn't initially want anesthesia after explaining to them why you would like to adminmister anesthesia and what they might feel without anesthesia 😀 😉 they'll often then want me to adiminister some anesthetic.

BTW, I shake the lip/cheek on every injection, administer atleast a full carpule with each and every buccal infiltration/mandibular block, and will administer 1 carpule for every 3 adjacent teeth in the maxilla.

 

[tx oms]

i have enough experience and have the experience that you guys can only dream off . The number of procedures that we do far out number that you do in 4 years and 1 year of practice. so don't try to dazzle me with your knowledge ( or the clear lack of).

Oh lord, this is too good to be true. After a long day of working on my house and car I come inside, eat dinner, watch a little TV, and turn on the computer. What, but before my very eyes is an awesome chance to crush another idiot! Thank you, toothie, for giving me an idiot to smite.

First, how do you know when you've injected 0.6cc? Does your carpule come graduated? Are you sure you didn't inject 0.599302cc? What about 6.02384cc? Holy ****, I'd sure hate for you to be off by that much! I hate Malamed's book b/c idiots like you quote it like the Bible and try to say that any deviation is outside of the standard of care. Stan Malamad doesn't set the standard of care.

Now, let me turn my hammer towards the quote above. I shall smash it like the self esteem of a zit-faced 8th grader. How can you have so much experience, presumably while using local anesthetics, and not know anything about local anasthesia, physiology, and pharmacology?

 

[ItsGavinC]

You might want to check yourself on this one Gavin. One of the malpractice seminiars given by my malpractice carrier addressed this exact issue. Where the Doc wants to administer anesthesia and the patient doesn't want it. The attorney said that if after you've explained to the patient what and why you want to do, and they don't want it, if you go against their wishes you're essentially committing battery 😱 I've even extracted 2 teeth(different patients) without anesthesia since they refused it (personally I think that thats more likely to be battery than administering anesthesia, but then again theres many things about the legal system that don't make sense)

I hear you. If that is the case then you are absolutely correct, however I interpreted her statement of "i requested that i didn't need it" to be more along the lines of "I don't think I need it but you're the doctor" rather than "I'm refusing it".

It's probably my mistake in interpreting her recollection of the situation. And, given that, the dentist could have made a mistake as well. The bottom line with this situation is that if the patient indeed requested no anesthesia yet still ended up receiving it, then SOME sort of discussion must have (or should have!) occured in the interim period regarding the issue.

 

[DDS2BE]

toothie, no offense, but you must be a pain in the as$ patient. Why? Because you think you know more then your doc. If that's the case, then why don't you do dental procedures on yourself all by yourself next time?!

 

[toofache32]

toothie, no offense, but you must be a pain in the as$ patient. Why? Because you think you know more then your doc. If that's the case, then why don't you do dental procedures on yourself all by yourself next time?!

One of our older Pros faculty did that in dental school. He prepped his 6 maxillary anteriors for crowns in the mirror. Then he made temporaries. Then he never got around to making the crowns. He would take off his temporaries and clean them for you if you didn't believe him.

This was in Memphis, and he was also Elvis's dentist back in the day.

 

[DDS2BE]

I can't judge the whole Europe, but in some places, having dental work done with anesthetics is a privilege which is not available to majority of the public. This is my only explanation to why toothie asks pre-dental questions and at the same time claiming to be an experienced dentist. Correct me if I’m wrong, but I did experience my having primary teeth pulled out without local anesthesia 😱 and I still remember the pain 😀

 

[J2AZ]

Shouldnt the Articane be saved for lower blocks rather than restorations on upper teeth? Granted I have never taken a class on anesth., yet I have assisted for over a year and never have I seen the dentist use articaine/septocaine when restoring upper teeth. From what I have observed 2% Lidocaine is more than enough for uppers and 4% is best when one is doing a crown or Rct on a lower posterior (ie longer procedure). You only had two fillings, one being an occlusal.

Is it possible that the dentist was unsure of her technique and wanted to make sure she got you numb the first time so she pulled out the 4%? She may have been intimidated by the fact that your are a dentist and didnt want you to think she couldnt get you numb the first time. Or, she just wanted to hit you hard the first time to save chair time.

 

[tx oms]

Shouldnt the Articane be saved for lower blocks rather than restorations on upper teeth? Granted I have never taken a class on anesth., yet I have assisted for over a year and never have I seen the dentist use articaine/septocaine when restoring upper teeth. From what I have observed 2% Lidocaine is more than enough for uppers and 4% is best when one is doing a crown or Rct on a lower posterior (ie longer procedure). You only had two fillings, one being an occlusal.

Is it possible that the dentist was unsure of her technique and wanted to make sure she got you numb the first time so she pulled out the 4%? She may have been intimidated by the fact that your are a dentist and didnt want you to think she couldnt get you numb the first time. Or, she just wanted to hit you hard the first time to save chair time.

2% lidocaine is fine for everything. Period. Articaine is generally used by people with poor technique who mistakenly believe articaine forgives all sins with its ultra-powerful super numbing death gun.

 

[lnn2]

2% lidocaine is fine for everything. Period. Articaine is generally used by people with poor technique who mistakenly believe articaine forgives all sins with its ultra-powerful super numbing death gun.

agree 100% 👍 According to my OMFS professor, articaine in an IA block has the risk of parathesia.

 

[DrJeff]

agree 100% 👍 According to my OMFS professor, articaine in an IA block has the risk of parathesia.

Check the latest research on that, the risk of parasthesia with lidocaine and articaine for an IAB is essentially the same. And BTW, it's an incredibly small risk, so the chances of you over your ENTIRE career administering an IAB where the patient will end up with a permanent parasthesia are about the same as you winning the lottery. A transient parasthesia you'll get from time to time, but you're just as likely to get that with plain 'ol mepivicaine as with articaine.

 

[mallorydmd]

1. it's not 1 carpule for each tooth. she had to anesthetize 2 different nerves for the different teeth, that is, #2 is the posterior superior alveolar nerve and #5 is the middle superior alveolar nerve. and depending on the size of the restoration she could have easily given more.

2. the cheek is shaken simply to distract you from any sharp sensation from the injection. it in no way harms you or effected the symptoms you are describing.

3. articaine is a much stonger anesthetic but it is usually metabolized quickly from the body. so 10 hours of being numb is unusual but also possible. your body took longer to process the anesthetic. no big deal. just inform your dentist next time that you would prefer a different anesthetic and explain the reasons.

4.the edema you experienced is because the needle peirced a blood vessel (artery or vein) and that vessel began to bleed out into a potential space. the filling of that space with blood caused the swelling and the color of the blood caused the bruising. the dentist should have know that she peirced the blood vessel by aspirating the syringe while injecting and also while pulling the needle out. by aspirating the syringe, she would have seen blood in the carpule, and could have promptly place firm pressure over that side of the face to cause a clot to form quickly and reduce bleeding thus reducing swelling, bruising and/or soreness later.

5.articaine is controversial for different reasons. it has only been available in the united states since 2000. it's a very powerfull anesthetic and can actually permanently damage nerves. studies have shown it to cause permanent paralysis to nerves in some cases. this is precisely why it highly recommended to never use articaine on mandibular blocks because those nerves have been shown to be more susceptible to damage. once again, your body is more sensitive to that anesthetic and i would recommend you inform your dentist to chart that you had this reaction of being numb for 10 hours and tell him/her you don't want it again. you can find this information on pubmed - efficacy of articaine: a new amide local anesthetic by stanley f. malamedan dds, suzanne gagnon md, dominique leblanc d pharm.

hope that helps.

 

[booshwa]

you can find this information on pubmed - efficacy of articaine: a new amide local anesthetic by stanley f. malamedan dds, suzanne gagnon md, dominique leblanc d pharm.

hope that helps.

FYI, Stanley F. Malamed....I talked with him last Thursday, and he would never let you hear the end of it if you pronounced his name wrong.