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  1. How to overcome failed local anaesthesia | British Dental Journal
  2. Local Anesthesia
  3. How to overcome failed local anaesthesia
  4. Complications of Local Anesthesia

Over-the-counter OTC topical anesthetics, such as benzocaine Orajel , can also help manage pain from:. Local anesthetics can also be given as an injection. Injectable anesthetics are typically used for numbing during procedures, rather than pain management. The lists above are general examples.

Several of these procedures, such as cataract surgery, can be done with either type of anesthetic. Your doctor will determine the best type for you based on several factors, including:. Just make sure to tell your doctor if you:. This usually only takes a few minutes. Tell your doctor right away if you start to feel any pain during the procedure. They may need to give you a higher dose. Local anesthesia usually wears off within an hour, but you may feel some lingering numbness for a few hours. As it wears off, you might feel a tingling sensation or notice some twitching.

Try to be mindful of the affected area while the anesthesia wears off. For OTC local anesthetics like Orajel, be aware that it may sting or burn a little when you first apply it. It can be toxic if too much is absorbed in your skin. A study estimates that only about 1 percent of people are allergic to local anesthetics. In addition, most allergic reactions to local anesthetics are due to a preservative in the anesthetic, rather than the drug itself. Yes, in certain instances, local anesthetics are safe for pregnant women. However, there are some considerations, including what type of anesthetic is used, how much is needed, and the stage of the pregnancy.

Also, the anesthetic does go into the fetal circulation. This means it goes to the baby. Considering this, it might be prudent to put off any elective procedure until after the pregnancy or later in the pregnancy. If you need a procedure with local anesthesia, talk to your doctor about the safety and any options for your unique situation. Local anesthesia is a relatively safe way to numb a small area before a procedure. It can also help manage pain on your skin or in your mouth. While it can occasionally cause side effects, this usually only happens in cases that involve doses above the recommended amount.

Some surgeries and procedures may be more painful than others. Here are 7 of the most painful ones. Novocaine is a local anesthetic that's often used in short procedures to numb a specific part of the body. But how long does it last? A surgical wound is a cut or incision that occurs during surgery. Learn about risks of infection, at-home care, and more.

How to overcome failed local anaesthesia | British Dental Journal

Blood clot formation, also known as coagulation, is your body's normal response in certain situations. Learn tips for preventing this dangerous…. Your oral health can significantly impact your general health. Find out why keeping your teeth and gums healthy is so important. The most likely defect in technique is faulty needle placement. Failure to aspirate before injection, which could lead to intravascular deposition of solution might also lead to failure of anaesthesia although this has never been proven. Success may be related to the speed at which the solution is deposited.

It is easy to imagine the anaesthetic being directed away from a nerve trunk during forceful injection. There is evidence in the surgical literature that the success of some techniques is increased with slower injection speeds. As far as conventional methods of local anaesthesia are concerned poor technique usually relates to mandibular anaesthesia, specifically failed inferior alveolar nerve block injections.

The best way to achieve success with the inferior alveolar nerve block is to use the direct technique where the dentist places the thumb intra-orally at the deepest concavity of the anterior ascending ramus and the index finger at the same height extra-orally on the posterior aspect of the ramus. The puncture point is half-way between the mid-point of the thumb nail and the pterygomandibular raphe and the needle is advanced through this point being delivered parallel to the occlusal plane from the premolar teeth of the opposite side.

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The proper bony end point is reached between 15 and 25 mm of penetration. The common causes of failure are touching bone too soon on the anterior ascending ramus rectified by swinging the syringe across the mandibular teeth on the same side, advancing 1 cm and then returning to the original angle of approach or injecting inferior to the mandibular foramen countered by injecting at a higher level. In most cases the dentist who experiences the odd failure rectifies the problem with a repeat injection, perhaps at a slightly higher level. An orthopantomogram may help in locating the position of the mandibular foramen.

In those cases where a second injection has not overcome the failure, an alternative approach to the inferior alveolar nerve should be considered. There are a number of approaches to the inferior alveolar nerve, including extra-oral techniques. Some of the intra-oral methods are described below. This is technically more difficult than the standard direct approach to the inferior alveolar nerve. The method relies upon deposition of local anaesthetic adjacent to the head of the mandibular condyle fig.

This is the plane of approach. The needle is introduced across the contralateral mandibular canine and directed across the mesio-palatal cusp of the ipsilateral upper second molar fig. The point of mucosal penetration is thus higher than with the conventional block and the needle is advanced until bony contact is made. The point of bony contact is the condylar head.

The needle is withdrawn slightly, and after aspirating a full cartridge is deposited. The patient should keep the mouth open for a few minutes until the subjective signs of inferior alveolar anaesthesia are reported. This method, 7 which is also known as the Vazirani-Akinosi closed-mouth technique, is useful when conventional block anaesthesia fails fig. It is simpler than the Gow-Gates method, and uniquely for intra-oral approaches to the inferior alveolar nerve, it does not rely upon contacting a bony end-point.

The patient has the mouth closed and the syringe, fitted with a 35 mm needle, is advanced parallel to the maxillary occlusal plane at the level of the maxillary muco-gingival junction. The needle is advanced until the hub is level with the distal surface of the maxillary second molar, by which stage it will have penetrated mucosa at a higher level than with the direct approach to the nerve. At this point a cartridge of solution is deposited.

The Gow-Gates and Akinosi techniques are both 'high' methods of blocking the inferior alveolar nerve; both anaesthetise the lingual nerve. In addition the Gow-Gates method will block conduction in the long buccal nerve occasionally this also happens with the Akinosi technique. The Gow-Gates and Akinosi methods are best reserved for those cases where the conventional block methods fail as they can produce more complications than the standard approach.

Inferior Alveolar Nerve block

The higher the needle is inserted the closer it is to the maxillary artery and the pterygoid plexus. Contacting the maxillary artery can cause pain and produce blanching because of arteriospasm, laceration of vessels in the pterygoid plexus can cause an alarming haematoma which is controlled by firm pressure but may produce post-injection trismus which may last for weeks. Other methods of anaesthetising man-dibular teeth include infiltration anaesthesia, incisive and mental nerve blocks, intraligamentary or periodontal ligament , intra-osseous and intra-pulpal methods.

Buccal infiltration anaesthesia in the mandible can be effective in some areas. Indeed in children this may the preferred technique when treating the deciduous dentition. When treating the lower premolar and anterior teeth a mental and incisive nerve block may overcome a failed inferior alveolar nerve block. When using this method 1. These techniques rely on the same mechanism to achieve anaesthesia, namely deposition of solution in the cancellous bone of the alveolus.

The intraligamentary method gains access to the cancellous space by the periodontium, the intra-osseous technique by way of a perforation through the buccal gingiva. They can be used in either jaw.

Local Anesthesia

This may be used both as a primary or a secondary technique. It has limitations as a principal method of anaesthesia such as variable duration but has been used to overcome failed conventional methods. The technique is equally effective with conventional or specialised syringes. Glass cartridges are used in this method as the plastic type deform under the pressures produced.

When administering intraligamentary injections the needle is inserted at the mesio-buccal aspect of the root and advanced until maximum penetration. A 12 mm 30 gauge is recommended although efficacy is independent of needle diameter. Around 0. When using an ordinary dental syringe 0. The injection must be delivered slowly, at least 10 seconds is recommended. Rapid injection can lead to tooth extrusion, indeed an inadvertent extraction has been reported as a result of this method of anaesthesia.

When using the intraligamentary method success is highly dependent upon the presence of adrenaline in the local anaesthetic solution. Intraligamentary injections produce a significant bacteraemia 17 and thus should not be given to patients at risk of infective endocarditis unless appropriate antibiotic prophylaxis has been provided. As with the intraligamentary injection this method can be performed using conventional or specialised equipment.

How to overcome failed local anaesthesia

Similarly it is more effective when a vasoconstrictor-containing solution is used. Specialised equipment consists of a matched perforator and needle. If the patient has radiographs of the tooth to be treated these are useful in locating the best inter-radicular zone for anaesthetic injection. If it is not already anaesthetised the gingiva in the area of perforation is infiltrated with a small volume 0. The region to perforate is within the attached gingiva about 2 mm below the gingival margin of the adjacent teeth in the vertical plane bisecting the interdental papilla. The perforator is fitted to a standard dental handpiece and advanced through the buccal cortex until the unmistakable drop into the cancellous space is experienced.

The perforator is removed and the small 6 mm 30 gauge needle is advanced through the defect into the cancellous bone where 0. Although there are aspects which preclude intra-osseous anaesthesia as a primary technique it is a useful adjunct to block anaesthesia. A technique of anaesthesia that can be useful in endodontics and oral surgery is the intra-pulpal method.

Unlike intra- ligamentary and intra-osseous techniques this method achieves anaesthesia as a result of pressure.

Key Points

Saline has been reported to be as effective as an anaesthetic solution when injected intra-pulpally. When a small access cavity is available into the pulp a needle which fits snugly into the pulp should be chosen.

Complications of Local Anesthesia

A small amount about 0. There will be an initial feeling of discomfort during this injection, however this is transient and anaesthetic onset is rapid. When the exposure is too large to allow a snug needle fit the exposed pulp should be bathed in a little local anaesthetic for about a minute before introducing the needle as far apically as possible into the pulp chamber and injecting under pressure. The foramina of importance in regional block anaesthesia in dentistry do not have a consistent location between patients. Many of the methods described above to surmount poor technique will overcome any problems resulting from anatomical variations.

Available radiographs may be helpful in anticipating this situation. Teeth may receive innervation from more than one nerve trunk Table 1. Accessory nerve supply can lead to failure of anaesthesia following both infiltration and regional block methods. Pulpal supply to upper molar teeth may arise from the greater palatine nerves and a buccal infiltration is unlikely to affect transmission by this source. Similarly maxillary anterior teeth can receive innervation from the naso-palatine nerve.

The solution for both these cases is a palatal injection. The long buccal nerve will occasionally provide innervation to the lower molar pulps and a long buccal block or mandibular buccal infiltration may be necessary for complete anaesthesia in such cases. The lingual nerve may also contribute pulpal supply to the mandibular teeth but this will normally be counteracted by the lingual nerve block given in association with the inferior alveolar nerve block.

However it will not be affected by the mental and incisive nerve block. Further accessory supplies innervate mandibular teeth. Such supply can be derived from the mylohyoid nerve, the auriculotemporal nerve and the upper cervical nerves. The mylohyoid branch leaves the main inferior alveolar trunk more than a centimeter superior to the mandibular foramen 21 so may not be affected by a conventional approach to the latter nerve. However, it may be anaesthetised using the techniques of Gow-Gates and Akinosi. Alternatively, a lingual infiltration adjacent to the tooth of interest may be effective.

The auriculotemporal nerve occasionally sends branches to the pulps of the lower teeth through foramina high on the ramus. When removing third molar teeth it is not unusual to discover that, despite an apparently effective lingual block, the disto-lingual gingiva is not anaesthetised.

This accessory supply is readily countered by injecting just disto-lingual to the third molar. In fact this finding is so common that a routine injection of about 0. When using regional block anaesthesia structures in the mid-line may not be satisfactorily anaesthetised as they receive bilateral innervation. A classic example is the failure of inferior alveolar or mental and incisive nerve blocks to anaesthetise a lower central incisor. The solution is to block the contralateral nerve with an inferior alveolar nerve block, incisive nerve block or buccal infiltration. Alternatively, an infiltration, intraligamentary or intra-osseous injection may be administered at the outset in this area.

The most obvious barrier to anaesthetic diffusion is the thick cortical plate of the mandibular alveolus which precludes infiltration anaesthesia in adults with the possible exception of the mandibular mid-line. The first molar region in the adult maxilla occasionally presents a similar problem. In this region the thick zygomatic buttress can prevent passage of the anaesthetic to the dental apices.

The answer to this problem is to inject mesial and distal to the first molar away from the buttress as the first molar can obtain supply from both posterior and middle superior alveolar nerves a posterior superior alveolar nerve block may be unsuccessful. Factors which can preclude access include trismus because of a number of causes and anatomical changes because of trauma or surgery.

Trismus is the most likely factor in practice and this is often because of an infective cause. Buccal infiltrations in the maxilla are still possible with the mouth closed. A way to anaesthetise the palatal tissues in the patient with trismus is to inject while advancing a needle toward the palate through the mesial and distal gingival papillae from the buccal side. The best way to achieve inferior alveolar anaesthesia in the patient with trismus is to use the Akinosi closed-mouth technique described above.

There are extra-oral approaches but these are not recommended in practice. Although methods of anaesthetising the nerve supply to the teeth are possible in the patient with trismus the practitioner must question the appropriateness of administering the injection. Can the proposed treatment be completed in such patients?

It may be that half-completed treatment is worse than none at all. It may be prudent to allow the trismus to resolve prior to dental treatment. It is apparent to all practitioners that teeth with inflamed pulps can be difficult to anaesthetise. A number of suggestions have been proposed to explain this finding. The classic explanation for this is that the low tissue pH in areas of inflammation affects the activity of the local anaesthetic solution by decreasing the concentration of the unionised lipophilic fraction which diffuses through nerve sheaths.

Similarly areas of inflammation have an increased blood supply due to vasodilatation and this might increase anaesthetic 'wash-out'. However, these answers do not explain the failure of regional block techniques where the solution may be deposited 4 or 5 cm from the area of inflammation. The most plausible explanation is that inflammation makes nerves hyperalgesic. However, no tooth is resistant to local anaesthesia. The practitioner therefore has to decide on the maximum volume of local anaesthetic he is willing to inject for that patient and be prepared to use up to that maximum to anaesthetise that tooth.

This may mean limiting treatment to only one tooth but if it takes the maximum safe dose — so be it. On no account should the predetermined safe maximum dose be exceeded. In healthy patients there is usually sufficient room for manoeuvre to administer a dose sufficient to halt conduction in the tooth without producing generalised central nervous system effects.

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  • The answer is to inject more solution. This does not have to be at the same site, eg the combination of infiltration and regional block anaesthesia can be used in the maxilla eg infiltration at the apex of an upper lateral incisor plus an infra-orbital nerve block. This can be supplemented with intraligamentary or intra-osseous injections if required. There are undoubtedly patients who do not do well with local anaesthesia but in whom the local anaesthetic appears to have been effective.

    This may be because of fear and apprehension. In such patients the use of sedative techniques can be helpful as successful anaesthesia is easier to achieve in the relaxed patient. When an initial local anaesthetic fails the best treatment is to repeat the injection; this will often lead to success. In the case of repeat block injections it is easier to palpate bony landmarks at the second attempt as the needle can be manoeuvred in the tissues painlessly.

    If a second injection fails then the alternative approaches discussed above should be employed namely: 'high' blocks, infiltrations to eliminate accessory supply, or one of the intra-osseous techniques fig. The broad arrows in 3b show the 'blunderbuss' approach to the tooth which has proved resistant to local anaesthesia in the past.

    When a practitioner is treating a patient who has had difficulty in being anaesthetised in the past, or has been referred from elsewhere because of failed local anaesthesia there is an argument for applying a 'blunderbuss' technique from the start — it is often difficult to gain a patient's trust at that session if they have been hurt therefore they should be given 'the best shot' at the outset. When this achieves success it is extremely satisfying. A technique suggested for patients who have experienced local anaesthetic failure in the mandible is this:. Conventional inferior alveolar and lingual block with lignocaine and adrenaline 1.

    There is no scientific evidence that changing the active agent increases duration or depth of anaesthesia. However, there are a number of reasons why changing the solution might offer an advantage. Firstly, with the combination suggested there is an increase in the amount of local anaesthetic without increasing the amount of adrenaline administered. This can be of particular importance in some medically-compromised individuals. Secondly, there is some evidence that the combination of lignocaine and prilocaine provides a greater spread of anaesthesia 25 and this may be of some clinical benefit.

    If subjective signs of inferior alveolar nerve block anaesthesia are not apparent after a second block then an Akinosi block is recommended with lignocaine and adrenaline.