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January 2015

Knowledge for Clinical Practice

Achieving Profound Local Anesthesia

The Challenges and Complexities in

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James L. Gutmann, DDS

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EDUCATIONAL OBJECTIVES

The overall goal of this article is to provide the reader with information on achieving profound local anes-thesia. On completion of this course, the participant will be able to do the following:

1. List the factors that the clinician must be aware of when providing local anesthesia for endodontic emergencies;

2. Describe the inflammatory and degenerative pro-cesses that occur in the presence of pulpal disease;

3. Describe the anatomical considerations in the maxilla and mandible that can complicate the achievement of profound local anesthesia;

4. Identify the alternative techniques that can be utilized for local anesthesia, where and how each of these may be used; and

5. Utilize tips provided in this article for evaluating the degree of anesthesia for the symptomatic mandibular molar.

ABSTRACT

The ability to achieve profound local anesthesia for patients in general, and endodontic patients in particu-lar, can be impacted by many factors. These include the inflammatory process, anatomical structures and neural variations. In order to efficiently and effec-tively manage endodontic emergencies in a relatively painless manner, the clinician must understand all of these considerations. Local anesthetic techniques for the maxillary and mandibular arches are available, as either a supplemental or alternative local anesthetic, in addition to inferior mandibular dental blocks and traditional infiltration techniques.

ABOUT THE AUTHORJames L. Gutmann, DDS, PhD (honoris causa), FACD, FICD, FADI, Dip ABE Professor Emeritus Baylor College of Dentistry, Texas A&M Health Science Center. He has a private practice limited to Endodontics in Dal-las, Texas and was President of the American Association of Endodontists from 2000-2001. Dr. Gutmann holds honorary memberships in dental societies in Colombia,

Lebanon, Greece, Costa Rica, Mexico, Thailand and South Africa as well as memberships in Alpha Sigma Nu National Jesuit Honorary Fraternity, Omicron Kappa Upsilon Dental Honorary Fraternity and Delta Sigma Delta Interna-tional Dental Fraternity. Dr. Gutmann has presented more than 800 lectures, papers, and continuing education courses in the United States and in 51 foreign countries on six continents. He has authored or co-authored over 275 articles in both dental journals and texts that address scientific, research, educational, and clinical topics. He is the senior author of an Endodontic text entitled “Problem Solving in Endodontics” published in its 4th edition in 2006, with the 5th edi-tion in 2011. He is also the senior co-author of text entitled “Surgical Endodon-tics,” published in 1991 and reprinted in 1994 and 1999; co-author of the text entitled “The Clinician’s Endodontic Handbook” published in 2000, 2005 and 2009; honorary Ph.D. from the University of Athens, Athens, Greece. He has received the Distinguished Dental Alumnus Award for 2000 from his alma ma-ter Marquette University School of Dentistry and the Award of Distinction for Continuing Education Activities from the Academy of Dentistry International; is a Fellow of the Academy; was named one of the top dentists/endodontists in the greater Dallas/Fort Worth area in “D” Magazine for 2004 – 2009; awarded an Honorary Professorship at the School of Stomatology, Wuhan University, Wu-han, China and in 2009 he received the Hayden-Harris Award from the Ameri-can Academy of the History of Dentistry. In 2011 he received The I. B. Bender Lifetime Educator Award from the American Association of Endodontists. AUTHOR DISCLOSURE: Dr. Gutmann does not have a leadership position or a commercial interest with any products that are mentioned in this article, or with products and services discussed in this educational activity. Dr. Gutmann can be contacted by emailing contentexpert@dental learning.net



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3January 2015

Introduction

How often have you heard a patient say, “On my last dental visit it took 5 shots of Novocain to do the dental work and I still could feel pain” or

something akin to this scenario; or if you are an endodon-tist, the comment is as follows, “My dentist can never get me numb and it always takes 5-6 shots and now I dread having this root canal.” These are common, daily scenarios that often contribute to patient avoidance of dental proce-dures, no matter how small.

The alleviation and prevention of dental pain resulting from pulpal or periradicular pathoses are prime objectives for the dental professional. The attainment of these goals is predicated on three major factors that must be addressed in every clinical case: • The clinician must thoroughly understand the inflam-

matory disease processes that affect the dental pulp and periradicular tissues

• The clinician must make a thorough subjective and ob-jective assessment of the patient’s chief complaint and integrate these findings with the spread of inflamma-tion, infection, and degenerative processes in the pulp and periradicular tissues

• A repair-predictive, treatment-oriented approach must result from these findings. Once acute pulpal pain, acute periradicular pain, acute

alveolar abscess, or cellulitis is identified/diagnosed, one of the greatest problems in managing the patient’s discomfort is the inability to provide adequate anesthesia. However, endodontic emergencies can be efficiently and effectively managed in a relatively painless manner when the clinician is aware of the following:

• Inflammatory and neural considerations in the pulp and periradicular tissues

• Osseous and neural variations in the area to be anesthe-tized

• Variable approaches to achieving anesthesia in both dental arches

• Patient-specific considerations • Obtaining anesthesia in the most challenging clinical

scenario.

Inflammatory and neural considerations in the pulp and periradicular tissues

Normal pulp tissue has a relatively high blood flow that is minimally influenced by vasodilator substances (products of irritation). This results, therefore, in minor increases in localized blood flow during irritation and inflammation.1 In the inflamed environment, capillary permeability appears to be more significant than blood flow with regard to the inflammatory response of the pulp. This set of circumstances rules out the concept of general-ized pulpal edema, in spite of the low compliance environ-ment within the tooth. Localized inflamed tissues undergo an increase in tissue pressure, which results in focal vascu-lar stasis, ischemia, and tissue necrosis. These focal areas of necrosis serve as additional insults within the pulp, and the subsequent cyclical episodes of inflammation and cellular death result in incremental and circumferential spread of tissue destruction.2

The periodic irregular inflammation and destruction of local tissues coupled with bacterial invasion partially explain the clinical experience of episodic pain. Further explanations for this episodic phenomenon may include



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neural fluctuation with cycles of increased and decreased nerve fibers and peptide cytochemicals; this is perhaps as-sociated with cycles of intrapulpal abscess expansion and repair.3-6 Interestingly, the sprouting of new nerve fibers and alterations in neuropeptides associated with a painful carious attack have been identified.6,7 Likewise, sustained severe pain might be interpreted as multiple areas of tissue simultane-ously undergoing demise. In many patients episodes of severe pain are often followed by the absence of symptoms, indi-cating the presence of either pulpal necrosis or an effective avenue of drainage from the inflammatory process.

The inflammatory and degenerative processes that occur in the presence of pulpal disease are basically the same as elsewhere in the body’s connective tissue.8 When coupled with root canal procedures, coronal leakage of bacteria, products from inferior dental restorations, and/or toxic root canal filling materials, the periradicular tissues will reflect a complex of both inflammation and repair. Histologically, the lesion consists predominantly of granu-lation tissue (exhibiting significant angioblastic activity), many fibroblasts, connective tissue fibers, an inflammatory infiltrate, and often a connective tissue encapsulation.9 The inflammatory infiltrate consists of plasma cells, lympho-cytes, mononuclear phagocytes, and neutrophils. Occasion-ally, cholesterol clefting is seen with foreign body giant cells. If adjacent strands of epithelium or rests of Malassez have been stimulated by the inflammatory response to

form a squamous epithelium-lined cavity filled with fluid or semisolid material, a cyst will develop.

As long as there is an egress of tissue irritants and bacteria from the root canal system, or there is a failure of the phagocytic macrophage system to control this irrita-tion, the histologic pattern of the periradicular lesion will be one of concomitant repair and destruction.10 Often this variable tissue response is subjected to superimposed inflammatory, infective or immunological processes. These changes will be reflected by the patient’s signs and symp-toms, moving from a chronic clinical state of minimal-to-no symptoms to an acute state with painful characteristics. It is this environment that the astute clinician must control with properly chosen and administered anesthetic solu-tions. Table 1 provides typical clinical signs and symptoms that usually exist with irreversible pulpitis with symptom-atic periapical/periradicular periodontitis.

The inflammation that accompanies pulpal and perira-dicular degenerative-infective changes results in a reduced pH in tissues over variable areas, depending on the extent and acuteness of the process. This has been suggested as the explanation for the difficulty in achieving quality anesthesia, as the ability of the weak anesthetic base (pKa 7.5 to 9.0) to dissociate is significantly affected.11 Others have suggested that the inflammation alters peripheral sensory nerve activity,12 possibly due to neuro-degenerative changes along the inflamed neural element

TABLE 1. Highlights of Clinical Findings for Symptomatic Pulpal & Periradicular Inflammation/Infection4-6

Pulpal Periradicular

History of pain Pain upon biting or percussion

Moderate to severe pain Mobile tooth

Spontaneous pain with increasing frequency Tenderness upon palpation

Lingering pain Swelling

Radiating, diffusing or localized pain Possible elevation of the tooth in the socket

Lingering pain from thermal stimulation Possible radiographic changes

The Challenges and Complexities in Achieving Profound Local Anesthesia

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distal from the inflammatory site.13,14 As suggested by Wong and Jacobsen,15 an increase in anesthetic concentra-tion (not necessarily volume) is required to lower the neu-ral action potential when attempting to achieve complete anesthesia in the presence of inflamed tissues. An alternate approach would be to administer the local anesthetic away from the area of inflammation, such as the use of a regional nerve block,16,17 especially in the case of extensive cellulitis or acute periapical abscess.

Osseous and neural variations in the area to be anesthetized

Variations in the osseous anatomy surrounding the tooth roots and aberrant neural structures have received renewed attention as potential impediments to the admin-istration of successful anesthesia. Common variations relative to the maxilla and mandible are discussed below.

Maxillary Arch Generally, the outer cortical plate of an adult’s maxil-

lary bone is thin and sufficiently porous to infiltrate anes-thesia effectively. However, in areas of the zygomaticoal-veolar crest (Figure 1), penetration of anesthetic solution to the middle superior alveolar nerve may be restricted,18 especially in children.16 Likewise, the absence of this neural

branch has been reported—requiring more extensive place-ment of the anesthetic solution to manage the first molar and premolars.19,20

The prominence of the anterior nasal spine (Figure 2) and floor of the piriform aperture may preclude approxi-mation of the root apices of the incisors. In the premolar and molar regions, the position of the palatal roots relative to the buccal cortical plate may require palatal infiltration anesthesia (Figure 3).

Mandibular Arch The mandibular foramen is the primary target for the

deposition of anesthetic solution for profound anesthesia of the mandibular teeth (Figure 4). While the foramen’s position is variable, it is usually found anterior to the midpoint of the ramus of the mandible when the anterior border of the mandible is the internal oblique ridge.21 This position is slightly above the occlusal level of the molars,22 although Nicholson21 defines it as being below the occlusal surface in 75% of the mandibles studied. The importance of this variability cannot be overemphasized to the clini-cian, as the angle and level of needle penetration must be reassessed and altered accordingly in many cases in which profound anesthesia is not readily achieved with a stan-dard approach.

Figure 1. The zygomatic arch or malar process often consists of dense bone that minimizes penetration of the anesthetic solution.

Figure 2. The anterior nasal spine may consist of dense bone that limits penetration of anesthetic solution.

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Rare, extreme variability in the course of the mandibu-lar canal has also been reported—even to the extent of bifidity.23-25 Conventional attempts at mandibular blocks in these cases may lead to failure. Two- or three-dimen-sional examination of panoramic views of the mandible or the use of Cone Beam CT scans are extremely helpful to anticipate such variations when necessary.26 Of all the variables that create controversy in achieving profound anesthesia in the mandible, the presence of accessory in-nervations has received the most attention.27 This ranges from the presence of well-defined foramina higher on the

internal surface of the ramus (Figure 4), in the coronoid or mandibular notch (Figure 5), and in the retromolar fossa (Figure 6),23,28-31 to the extension to and innervation of both posterior and anterior teeth by branches of the mylohyoid nerve,29,32,33 the median symphyseal crossover from branches of the incisive nerve,9,33,34 and the trans-verse cervical cutaneous nerve that may intermingle with fibers of the mental nerve or enter the mental foramen and continue posteriorly, innervating the premolars or molars.12,18,35,36 Support for this speculated phenomenon is primary empirical.37-39 In-depth discussions of the com-

FPO

FPO

A

Figures 4a and b. Opposing medial surfaces of the ramus of a mandible that demonstrate the position of the main foramen (arrows) and accessory foramina (AF) superior to this main foramen.

B

Figures 3a and b. The thickness of the palatal bone and position of the palatal root may necessitate the use of a palatal injection to obtain profound anesthesia.

B

A


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plexities of mandibular innervations can be found in the literature.39,40

Variable approaches to achieving anesthesia in both dental arches

There are a number of approaches that can be used for the maxillary and mandibular arches to achieve anesthesia. Maxillary Arch

Considering the potential impediments to achieving profound anesthesia in the maxillary teeth, the suggested sequence for administering anesthetic is as follows: 1. Supraperiosteal injection: Infiltrate the facial tissues

with the needle tip in the immediate area of the root apex at an angle of 45 to 90 degrees

2. Palatal injection: Use to supplement facial infiltration when necessary

3. Regional injection or block: Use when infiltration fails or when extensive infection/swelling is present

4. Intraligamentary ligament (periodontal ligament) injec-tion: Use multiple injection sites (may be limiting in scope when extensive discomfort is present)

5. Intraseptal injection: Use when bone is less dense 6. Intraosseous injection: Use a rotary instrument for os-

seous penetration and be careful with the amount of solu-tion injected. Use as an adjunct with intrapulpal injection.

Mandibular Arch The suggested sequence for achieving profound anes-

thesia for mandibular teeth is as follows: 1. Inferior alveolar injection: Administer by the traditional

method, taking into account the following possible variations: • Gow-Gates Injection* • Akinosi-Vazirani Closed-Mouth Injection:*

2. Buccal infiltration: Use of soft tissue anesthesia. 3. Mylohyoid infiltration: Use if teeth continue to be inac-

cessible endodontically. 4. Mental foramen infiltration: Use if teeth continue to

be inaccessible endodontically. Consider as an adjunct to any inferior alveolar nerve block (IANB), especially when the tooth is symptomatic. (Note the discussion

Figure 5. Accessory foramina in the coronoid notch.Figures 6a and b. Examples of foramina in the retromolar pad region.

A

B

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above on the cervical transcutaneous nerve.) 5. Intraligamentary injection (Periodontal Ligament): Use

multiple injection sites (may be limited in scope when extensive discomfort is present).

6. Intraseptal injection: Use when bone is less dense. 7. Intraosseous injection: Use a rotary instrument for osse-

ous penetration and be careful with the amount of solu-tion injected. Use as adjunct with intrapulpal injection. *The use of these two alternative injections has received

renewed interest in the dental community.27 They can be used for any type of dentistry performed in the mandibular arch and their use can be advantageous when the patient reports a history of failed IANBs or when oral opening is limited. However, present dental curricula do not afford the dental student the opportunity to learn these techniques at a level of competency. For the practicing dentist, the ability to learn these techniques and achieve success in their application is available through continuing educa-tional courses.

Patient considerations Assessment of the patient’s pain level and perception of

pain is essential in the provision of pain-free dental treatment. A history of a patient’s inability to be anesthetized to the proper level must be noted, especially when considering an IANB. Furthermore, following the administration of any anesthetic the clinician must wait for an adequate amount of time for anesthesia to occur before initiating emergency treatment. Early treatment intervention that results in pain only lessens the patient’s confidence, while decreasing the pain threshold. Every effort should be made to determine that profound anesthesia is present before initiating any dental, and certainly any endodontic, emergency procedure (see sec-tion below on tips for evaluating the degree of anesthesia for the symptomatic mandibular molar.)

Obtaining anesthesia in the most challenging clinical scenario

The clinical challenge in obtaining profound anesthesia that has received significant attention in the dental litera-

ture is the mandibular molar (in particular the first mo-lar) when the diagnosis is irreversible pulpitis with acute (symptomatic) periapical (periradicular) periodontitis.41 Achieving profound and lasting anesthesia in this situation is possibly the most difficult task for both the neophyte and the experienced clinician. Failure rates for the IANB can reach as high as 30-45% when proper technique is used.42 Even when patients are asymptomatic, failure to achieve profound anesthesia in the first mandibular molar may run as high as 15-20%.40,42,43 Multiple studies have recommended the use of supplemental infiltrations in both symptomatic and asymptomatic patients43-46 or the use of alternative anesthetic solutions.43,46-51 When considering both clinically advocated alternatives, neither has been fully successful. Moreover, studies from both the USA and other countries have shown a higher incidence of paresthe-sia following the administration of these alternative solu-tions (4% prilocaine and 4% articaine) for the IANB,52 although in select areas it did not differ much from the use of 2% lidocaine.53

The numerous reasons cited for the high failure rate encountered with the IANB include the thickness of the cortical plate of bone, soft tissue thickness and accessory or cross innervations,54 as previously discussed. Physiol-ogical reasons that have been identified include a de-crease in local pH, tachyphylaxis of anesthetic solutions and activation of nociceptors (including tetrodoxtin and capsaicin-sensitive transient receptor potential vanilloid type).55 From a clinical perspective, the cause of failure is more often attributed to failure in the technique of needle placement,56 time of delivery of the solution50 and failure to give the anesthetic sufficient time to penetrate into the target zone before starting any procedure.57

Three alternative techniques for the administration of anesthetic solution for mandibular molar anesthesia in the case of the symptomatic tooth are: 1) the intraligamentary injection,58-61 2) the intraosssseous injection,61-65 and 3) the intrapulpal injection.66-68 Prior to considering these injections, consider a mental injection as in many clinical situations this may be sufficient to achieve the desired profound anesthesia.


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The intraligamentary injection can be used as a primary or secondary technique.58,61 However this approach may have some limitations, such as anesthesia of short dura-tion, pain at the time of injection (if a primary injection), pain or soreness following the loss of anesthesia, elevation of the tooth in its alveolus and an elevated heart rate.59,60,69 A 27- or 30-gauge needle is recommended for this injec-tion and should be placed in the gingival sulcus on the mesial and distal aspects of the tooth (Figure 7). With the bevel oriented toward the root surface, the needle is advanced into the periodontal ligament between the root surface and the adjacent alveolar bone. The solution must be placed under pressure so that it will be redirected into the surrounding cancellous bone through fenestrations in the alveolar socket. Anesthesia is usually rapid, but even here the clinician is cautioned to wait a few minutes prior to commencing treatment.

The intraosseous injection can be performed using standard or specialized equipment. Radiographs are nec-essary to locate the site of injection — the interradicular bone. Initially, the soft tissue over the site of planned pen-etration is infiltrated with a few drops of local anesthetic solution. The site is usually considered to be within the at-tached gingival about 2-3 mm below the gingival margin of adjacent teeth (or 5 mm below the marginal gingiva) in a vertical plane bisecting the interdental papilla.57,61 Subse-quently, the bone is penetrated slowly with a small, sterile round bur. Once penetrated, a small needle is placed in the opening and a minimal amount of anesthetic solution (with no vasopressor, such as mepivacaine) is injected under pressure. Clinicians have noted that when this injec-tion is used there is rapid attainment of anesthesia with sufficient duration for use with mandibular molars.63,69-72 Recent in vivo research in animals has identified the concentration of lidocaine around the root apices follow-ing the intraosseous injection, which would explain the clinical observations.73

There are some potential dangers associated with the intraosseous technique,64 including damage to root structure, a persistent sinus tract opening at the site of

injection, breaking of a needle in the bone during delivery of the anesthetic solution under pressure, postoperative pain, swelling and infection. This technique should not be used in the presence of acute periapical infections or gross periodontal disease.

Even when appropriate attempts have been made to anesthetize a painful tooth, failure may occur. In these cases an intrapulpal injection can be used, which achieves pain control due to the pressure applied during its place-ment.68 This technique may initially evoke a painful response until the pulp has been penetrated. Therefore, attention to proper technique is mandatory. If the pulp is pathologically or traumatically exposed, the procedure is simple. However, if the pulpal chamber has not been penetrated, it will be necessary to gain entrance to the chamber with the least amount of patient discomfort. A No. 1 or 2 round bur is used in short incremental strokes to cut into the center of what would normally be the outline of the access opening preparation (or directed to the highest pulp horn). If the bur penetrates a few tenths of a millimeter at a time into the tooth, severe discomfort is minimized, and access to the pulp is achieved. A 30-gauge needle is passed into the small opening in the roof of the pulpal chamber, and the anesthetic agent is injected during

Figure 7. Placement of the anesthetic needle in the gingival sulcus during the intraligamentary injection.

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penetration (Figure 8a). Often only a few drops of solution are necessary to anesthetize the pulpal tissue (Figure 8b). It should be noted, however, that the intrapulpal technique may anesthetize only the coronal pulpal tissue and vital tis-sue in the canals may not have been properly anesthetized. Further injections into the canal orifices may be necessary prior to a painless pulpectomy. In cases of acute pulpal pain without excessive pain to percussion or biting, an alternative treatment is to limit the emergency procedure to a pulpotomy, and to reschedule the patient for the pulpectomy procedure.67

Tips for evaluating the degree of anesthesia for the symp-tomatic mandibular molar

Following proper delivery of the anesthetic solution

used in an IANB and a mental injection, patients generally report a tingling sensation followed by numbness of the lip. However, these responses may not indicate profound pulpal anesthesia or complete anesthesia of the support-ing, periradicular tissues. Two easy ways to determine the depth of anesthesia are to test the tooth with a cold stimu-lus (especially if pain to cold was a chief complaint) and to percuss the tooth with a mirror handle. The absence of abnormal responses would indicate that is it clinically ac-ceptable to begin treatment. If the patient experiences any pain during the evaluation, the clinician must reassess the techniques used, redo the same injections, or alternatively go immediately to one of the injections discussed above (preferably using the intraligamentary injection first and if necessary the intraosseous injection).

Conclusions Many factors impact the ability to achieve profound local anes-

thesia for patients in general, and endodontic patients in particular. Local anesthesia techniques are available for use in the maxillary and mandibular arches to help overcome these challenges, either as alternative or supplemental local anesthesia. Profound local anes-thesia is necessary to efficiently and effectively manage endodontic emergencies in a relatively painless manner, and the clinician must understand the considerations involved and be familiar with avail-able anesthesia techniques.

References 1. Heyeraas KJT. Vascular reactions in the dental pulp during

inflammation. Acta Odontol Scand 1983;4:247-256. 2. Van Hassel HJ. Physiology of the human dental pulp. Oral Surg

1971;32:126-134. 3. Newton CW, Hoen MM, Goodis HE, Johnson BR, McClanahan

SB. Identify and determine the metric, hierarchy, and predic-tive value of all the parameters and/or methods used during endodontic diagnosis. J Endod 2009;35:1935-1644.

4. Levin LG, Law AS, Holland GR, Abbott PV, Roda RS. Identify and define all diagnostic terms for pulpal health and disease states. J Endod 2009;35:1645-1657.

5. Gutmann JL, Baumgartner JC, Gluskin AH, Hartwell GR, Walton RE. Identify and define all diagnostic terms for periapical/peri-radicular health and disease states. J Endod 2009;35:1658-1675.

6. Byers MR, Taylor PE, Khayat BG, Kimberly CL. Effects of injury and inflammation on pulpal and periapical nerves. J Endod 1990;16:85-91.

Figures 8a and b. Placement of a 30-gauge needle directly into the exposed pulp of an anterior tooth following a traumatic ex-posure; the surrounding tissues were swollen and not suitable for the use of a standard injection(a), and placement of a 30-gauge needle in a pulpal exposure to achieve intrapulpal anesthesia (b).

A

B


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7. Yamaura Y. Immunohistochemical investigation on the nerve fibers of the dental pulp after cavity preparation. Jpn J Conserv Dent 1987;30:824-838.

8. Simon JHS. Pathology. In: Cohen S, Burns R (eds). Pathway of the Pulp, ed. 5. St Louis: Mosby-Year Book, 1991:350-374.

9. Weiner S, McKinney R, Walton R. Characterization of the periapical surgical specimen. Oral Surg Oral Med Oral Pathol 1972;53:293-302.

10. Torabinejad M, Walton RE, Ogilvie Al. Periapical pathosis In: Ingle Jl, Taintor JF (eds). Endodontics, ed. 3. Philadelphia: Lea & Febiger, 1985:419-445.

11. deJong RH, Cullen SC. Buffer-demand and pH of local an-esthetic solutions containing epinephrine. Anesthesiology 1963;24:801.

12. Rood JP. Some anatomical and physiological causes of failure to achieve mandibular analgesia. Br J Oral Surg 1977-1978;15:75-82.

13. Najjar TA. Why can’t you achieve adequate regional anesthesia in the presence of infection. Oral Surg Oral Med Oral Pathol 1997;44:7-13.

14. Wallace JA, Michanowicz AE, Mindell Rd, Wilson EG. A pilot study of the clinical problem of regionally anesthetizing the pulp of an acutely inflamed mandibular molar. Oral Surg Med Oral Pathol 1985;59:517-521.

15. Wong MKS, Jacobsen PL. Reasons for local anesthesia failures. J Am Dent Assoc 1992;123:69-73.

16. Quin CL, Malamed SF. Local anesthetic considerations in dental specialties. In: Malamed SF. Handbook of Local anesthesia, ed. 3. St Louis: Mosby-Year Book, 1990:233-242.

17. Evers H, Haegerstam G. Introduction to Dental Local Anesthe-sia. Fribourg: Mediglobe, 1990:91.

18. Philips WH. Anatomic considerations in local anesthesia. J Oral Surg 1943;1:112-121.

19. Heasemen PA. Clinical anatomy of the superior alvelolar nerves. Br J Oral Maxillofac Surg 1984;22:439-447.

20. Loetscher CA, Walton RE. Patterns of innervations of the maxil-lary molar: a dissection study. Oral Surg Oral Med Oral Pathol 1988;65:86-90.

21. Nicholson ML. A study of the position of the mandibular fora-men in the adult human mandible. Anat Rec 1985;212:110-112.

22. Bremer G. Measurements of special significance in connection with anesthesia of the inferior alveolar nerve. Oral Surg Oral Med Oral Pathol 1952;5:966-988.

23. Carter RB, Keen EN. The intramandibular course of the inferior alveolar nerve. J Anat 1971;108;433-440.

24. Heaseman PA. Variation in the position of the inferior den-tal canal and its significance to restorative dentistry. J Dent 1988;16:36-39.

25. Grover PS, Lorton L. Bifid mandibular nerve as a possible cause of inadequate anesthesia in the mandible. J Oral Maxillofac Surg 1983;41:177-179.

26. Patel S. New dimensions in endodontic imaging: part 2. Cone beam computed tomography. Int Endod J 2009;42:463-475.

27. Haas DA. Alternative mandibular nerve block techniques. A review of the Gow- Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques. J Amer Dent Assoc 2011;142(9 suppl):8S-12S.

28. Loizeaux AD, Devos BJ. Inferior alveolar nerve anomaly. J Ha-waii Dent Assoc 1981;12:10-11.

29. Jablonske NG, Cheng CM, Cheng LC, Cheung HM, Unusual origins of the buccal and mylohyoid nerves. Oral Surg Oral Med Oral Pathol 1985;60:487-488.

30. Casey DM. Accessory mandibular canals. N Y State Dent J 1978;44;:232-233.

31. Haveman CW, Debo HG. Posterior accessory foramina of the human mandible. J Prosthet Dent 1976;35:462-468.

32. Madeira MC, Percinoto C, Silva MGM. Clinical significance of supplementary innervations of the lower incisor teeth: a dis-section study of the mylohyoid nerve. Oral Surg Oral Med Oral Pathol 1978;46:608-614.

33. Frommer J, Mele FA, Monroe CW. The possible role of the mylohyoid nerve in mandibular posterior tooth sensation. J Am Dent Assoc 1972;85:113-117.

34. Gardner ED, Gray DJ, O’Rahilly R. Anatomy: A Regional Study of Human Structure, ed. 4. Philadelphia: Saunders, 1975;630-632, 662-673.

35. Rood JP. The nerve supply of the mandibular incisor region. Br Dent J 1977;143:227- 230.

36. Cook WA. The cervical plexus and its probable role in the oral operators field. Dent Items Int 1951;73;356-361.

37. Rood JP. The analgesia and innervations of mandibular teeth. Br Dent J 1974;140:237-239.

38. Chapnick L. Nerve supply to the mandibular dentition: a review. J Can Dent Assoc 1980;46:446-448.

39. Roda RS, Blanton PL. The anatomy of local anesthesia. Quintes-sence Int 1994;25:27-38.

40. Nusstein J, Reader A, Drum M. Local anesthesia strate-gies for the patient with a “hot” tooth. Dent Clin North Am 2010;54:237-247.

41. Malamed SF. Techniques of mandibular anesthesia. In: Hand-book of Local Anesthesia. 5th ed, St. Louis, Mosby 2004 42. Potocnik I, Bajrovi F. Failure of inferior alveolar nerve block in endodontics. Endod Dent Traumatol 1999;15:247-251.

42. Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving lo-cal anesthesia. J Am Dent Assoc 1984;108:205-208.

43. Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efficacy of articaine versus lidocaine as a supplemen-tal first molar after an inferior alveolar nerve block. J Amer Dent Assoc 2008;139:1228-1235.

44. Aggarwal V, Jain A, Kabi D. Anesthetic efficacy of supplemental buccal and lingual infiltrations of articaine and lidocaine after an inferior alveolar nerve block in patients with irreversible pulpitis. J Endod 2009;35:925-929.

45. Fan S, Chen WL, Pan CB, et al. Anesthetic efficacy of inferior alveolar nerve blocks plus buccal infiltration or periodontal liga-ment injections with articaine in patient with irreversible pulpitis

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in the mandibular first molar. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e89-93.

46. Meechan JG. The use of the mandibular infiltration anesthetic technique in adults. J Amer Dent Assoc 2011;142(9 suppl)19S-24S.

47. Tortamano IP, Siviero M, Costa CG, et al. A comparison of the anesthetic efficacy of articaine and lidocaine in patients with ir-reversible pulpitis. J Endod 2009;35:165- 168.

48. Claffey E, Reader A, Nusstein J, et al. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with ir-reversible pulpitis. J Endod 2004;30:568-571.

49. Mikesell P, Nusstein J, Reader A, et al. A comparison of artic-aine and lidocaine for inferior alveolar nerve blocks. J Endod 2005;31:265-270.

50. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a pro-spective randomized double-blind cross-over study. J Endod 2006;32:296-298.

51. Robertson D, Nusstein J, Reader A, Beck M, McCartney M. The anesthetic efficacy of articaine in buccal infiltration of mandibu-lar posterior teeth. J Amer Dent Assoc 2007;138:1104-1112.

52. Garisto G, Gaffen AS, Lawrence HP, Tenenbaum HC, Haas DA. Oc-currence of paresthesia after dental local anesthetic administration in the United States. J Amer Dent Assoc 2010; 141:836-844.

53. Pogrel A. Permanent nerve damage from inferior alveolar nerve blocks – an update to include articaine. CDA Journal 2007;35:271-273.

54. Malamed SF. Is the mandibular nerve block passé? J Amer Dent Assoc 2011;142(9 suppl):3S-7S.

55. Hargreaves KM, Keiser K. Local anesthetic failure in endodon-tics. Mechanism and management. Endod Topics 2002;1:26-29.

56. Meechan JG. How to overcome failed anaesthesia. Br Dent J 1999;186:15-20.

57. Madan GA, Madan SG, Madan AD. Failure of inferior alveolar nerve blocks. J Amer Dent Assoc 2002:133:843-846.

58. Walton RE, Abbott BJ. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc 1981;103:571-575.

59. Smith GN, Walton RE. Periodontal ligament injection: distri-bution of injected solutions. Oral Surg Oral Med Oral Pathol 1983;55:232-238.

60. Rakusin H, Lemmer J, Gutmann JL. Periodontal ligament injection: clinical effects on tooth and periodontium of young individuals. Int Endod J 1986;19:230-236.

61. Moore PA, Cuddy MA, Cooke MR, Sokolowski CJ. Periodontal ligament and intraosseous anesthetic injection techniques. Alternatives to mandibular nerve blocks. J Amer Dent Assoc 2011;142(9 suppl):13S-18S.

62. Replogle K, Reader A, Nist R, et al. Anesthetic efficiency of the

intraosseous injection of 2% lidocaine (1:100,000 epinephrine) and 3% mepivacaine in mandibular first molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:30-37.

63. Parente SA, Anderson RW, Herman WW, et al. Anesthetic ef-ficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endod 1998;24:826- 828.

64. Small JC, Witherspoon DE, Regan JD, Hall E. Procedural mis-haps with trephinebased intraosseous anesthesia. Texas Dent J 2011;128:23-30.

65. Leonard MS. The efficacy of an intraosseous injection system of delivering local anesthetic. J Amer Dent Assoc 1995;126:81-86.

66. Birchfield J, Rosenberg PA. Role of anesthetic solution in in-trapulpal anesthesia. J Endod 1975;1:26-27.

67. Gutmann JL. Endodontic emergency treatment. J Calif Dent Inst Contin Educ 1992;32:31-48.

68. Van Gheluwe J, Walton R. Intrapulpal injection: factors related to effectiveness. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:38-40.

69. Brkovic BM, Savic M, Andric M, Jurisic M, Todorovic L. Intra-septal vs. periodontal ligament anaesthesia for maxillary tooth extraction: quality of local anaesthesia and haemodynamic response. Clin Oral Investig 2010;14:675-681.

70. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3% mepi-vacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-682.

71. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100.000 epinephrine in irreversible pulpitis. J Endod 1998;24:487-491.

72. Nusstein J, Kennedy S, Reader A, Beck M, Weaver J. Anesthetic efficacy of the supplemental X-tip intraosseous injection in patients with irreversible pulpitis. JJ Endod 2003;29:724-728.

73. Goto T, Mamiya H, Ichinobe T, Kaneko Y. Localization of 14C-labeled 2% lidocaine hydrochloride after intraosseous anesthe-sia in the rabbit. J Endod 2011;37:1376- 1379.

WebliographyBecker DE, Reed KL. Essentials of Local Anesthetic Pharmacology. Anesth Prog. 2006; 53:98–109. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1693664/pdf/i0003-3006-53-3-98.pdfHolliday R, Jackson L. Superior position of the mandibular foramen and the necessary alterations in the local anaesthetic technique: a case report. Brit Dent J. 2011;210:207 - 211. Abstract available at: http://www.nature.com/bdj/journal/v210/n5/full/sj.bdj.2011.145.html

13January 2015

1. After a thorough assessment of the patient’s chief complaint, the clinician must integrate these findings with __________.a. the spread of inflammationb. any infection presentc. the degenerative processes in the pulp and periradicular tissuesd. all of the above

2. An increase in tissue pressure at the site of inflammation results in __________.a. tissue necrosisb. ischemiac. focal vascular stasisd. all of the above

3. The __________ is an important anatomical landmark in the maxilla that may prevent good penetration of the anesthetic solution for the mesial buccal root of the first molar.a. nasal spineb. piriform aperturec. zygomatic processd. tuberosity

4. The absence of symptoms following severe pain may indicate __________.a. pulpal recoveryb. periodontal necrosisc. pulpal necrosisd. all of the above

5. When the dental pulp becomes inflamed its ability to respond favorably is most likely due to __________.a. generalized tissue edemab. strangulation of the blood flowc. direct influence of bacteriad. the direct alterations in capillary permeability

6. __________ are a component of the inflammatory infiltrate. a. Lymphocytesb. Fibroblastsc. Neutrophilsd. a and c

7. __________ is/are a significant finding in pulpal inflammation.a. Swellingb. Spontaneous painc. Pain upon bitingd. Radiographic changes

8. In the premolar and molar regions, the position of the __________ roots relative to the cortical plate may require __________ infiltration anesthesia.a. palatal; palatalb. palatal; buccalc. buccal; buccal d. buccal; palatal

9. It has been suggested that inflammation alters __________ sensory nerve activity.a. centralb. peripheralc. regionald. none of the above

10. A significant characteristic of the dental pulp that has been noted in response to dental caries is __________.a. loss of sensationb. decreased inflammatory infiltratec. sprouting of new nerve fibersd. an influx in the phagocytic macrophage system

11. When attempting to lower the neural action potential in inflamed, painful tissues, __________.a. an increase in anesthetic concentration is necessaryb. an increase in anesthetic volume is necessaryc. a regional nerve block is necessaryd. multiple types of anesthetic must be delivered

12. In areas of the zygomaticoalveolar crest, penetration of anes-thetic solution to the __________ nerve may be restricted.a. upper superior alveolarb. middle alveolarc. lower superior alveolard. middle superior alveolar

13. The mandibular foramen is usually found __________ to the midpoint of the ramus of the mandible.a. anteriorb. posteriorc. superior d. inferior

14. For a supraperiosteal injection, it is recommended to infiltrate the facial tissues with the needle tip __________.a. at an angle of 45 to 90 degreesb. at an angle of 25 to 35 degreesc. in the immediate area of the rootd. a and c

15. A regional injection or block should be used in the maxilla when __________.a. infiltration failsb. extensive infection/swelling is presentc. the patient prefers this oned. a or b

16. A history of a patient’s inability to be properly anesthetized must be noted, especially when considering __________.a. an infiltration injectionb. an intraseptal injectionc. an inferior alveolar nerve blockd. all of the above

CEQuizThe Challenges and Complexities in


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17. __________ is the variable that has received the most attention in inability to obtain good anesthesia in the mandibular arch.a. Accessory innervationsb. The type of anesthetic solutionc. The presence of bifidity of the mandibular canald. The coronoid notch

18. The use of the Akinosi-Vazirani closed-mouth injection for mandibular anesthesia is recommended when __________.a. there is failure of the mental injectionb. there is a history of inferior alveolar nerve block failurec. an abscess is present in the premolar regiond. the Gow-Gates injection cannot be used

19. A limitation of the intraligamentary injection is the fact that __________.a. a hole must be made in the boneb. pain may be present following loss of anesthesiac. a large-bore needle is requiredd. achievement of profound anesthesia may take some time

20. When considering the use of the intraosseous injection which of the following statements is most accurate?a. Specialized equipment is essentialb. The incision for penetration is made in the gingival sulcusc. Rapid anesthesia is usually obtainedd. The injected solution tends to focus in the periodontal ligament

that surrounds the tooth

21. Failure rates for the inferior alveolar nerve block can reach as high as __________ when a proper technique is used.a. 10-15%b. 20-35%c. 30-45%d. 40-55%

22. The site for an intraosseous injection is usually considered to be within the attached gingival about __________ the gingival margin of adjacent teeth.a. 1-2 mm belowb. 1-2 mm abovec. 2-3 mm belowd. 2-3 mm above

23. The intraosseous injection should not be used in the presence of __________.a. gross periodontal diseaseb. acute periapical infectionsc. gingivitisd. a or b

24. Recent in vivo research in animals has identified the concentration of lidocaine around the root apices following the __________ injection.a. intraligamentaryb. intraosseousc. intraseptald. none of the above

25. An intraseptal injection can be used when bone is __________.a. more denseb. less densec. necroticd. none of the above

26. The inflammation that accompanies pulpal and periradicular degenerative-infective changes results in a __________ pH in tissues over variable areas.a. neutralb. increasedc. decreasedd. any of the above

27. Mylohyoid infiltration can be used if __________.a. teeth continue to be inaccessible periodontallyb. teeth continue to be inaccessible endodonticallyc. the patient prefers thisd. a and b

28. Which of the following statements is true regarding the degree of anesthesia obtained in the mandibular arch?a. Palpation can be used to assess the degree of anesthesiab. Percussion can be used to assess the degree of pulpal

anesthesiac. Failure using the inferior alveolar nerve block can run as

high as 60%d. Even after using all standardapproaches to achieving profound

anesthesia, an intrapulpal injection may still be necessary

29. __________ is an easy way to determine the depth of anesthesia. a. Testing the tooth with a cold stimulusb. Testing the tooth with a sour stimulusc. Percussing the tooth with a mirror handled. a and c

30. Tetrodoxtin is a __________.a. toxinb. nociceptorc. chemical with osteoblastic activityd. none of the above


CE QUIZ

15January 2015

The Challenges and Complexities in Achieving Profound Local Anesthesiawww.dentallearning.net/ALA-ceCE ANSWER FORM (E-mail address required for processing)

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

QUIZ ANSWERSFill in the circle of the appropriate answer that corresponds to the question on previous pages.

EDUCATIONAL OBJECTIVES1. List the factors that the clinician must be aware of when providing local anesthesia for endodontic

emergencies;2. Describe the inflammatory and degenerative processes that occur in the presence of pulpal disease;3. Describe the anatomical considerations in the maxilla and mandible that can complicate the achievement of

profound local anesthesia;4. Identify the alternative techniques that can be utilized for local anesthesia, where and how each of these may

be used; and5. Utilize tips provided in this article for evaluating the degree of anesthesia for the symptomatic mandibular molar.

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