Local Anesthesia for the Cerec Appointment Stanley F. Malamed, DDS Dentist Anesthesiologist Emeritus Professor of Dentistry Ostrow School of Dentistry of USC Los Angeles, California, USA
Stanley F. MALAMED, DDS Dentist Anesthesiologist Emeritus Professor of Dentistry Ostrow School of Dentistry of USC I have a relationship with the following company that may be relevant to this presentation. I am a paid consultant to: Septodont, Inc OraPharma ESTERS AMIDES Short - Duration LAs - USA Cocaine Articaine ~ 30 minutes Procaine Tetracaine Benzocaine Chloroprocaine Propoxycaine 1948 Bupivacaine Lidocaine Mepivacaine Prilocaine Mepivacaine 3% No vasoconstrictor Prilocaine 4% No vasoconstrictor
Long - Duration LAs - USA > 90 minutes Intermediate - Duration LAs - USA ~ 60 minutes Bupivacaine 0.5% + vasoconstrictor Articaine Lidocaine Mepivacaine Prilocaine 4% + vasoconstrictor 2% + vasoconstrictor 2% + vasoconstrictor 4% + vasoconstrictor Pain Control Options Crown preparation Mandibular Molar Inferior alveolar nerve block Time frame? 30-40 minutes Buccal infiltration -
Pain Control Options Inferior Alveolar nerve block Inferior alveolar nerve block Advantages 1. More extensive profound pulpal anesthesia Multiple crown preparations Inferior Alveolar nerve block Disadvantages 1. Slower onset of pulpal anesthesia 2. Prolonged duration of soft tissue anesthesia Lip & tongue How long does it take for pulpal anesthesia to develop?
Intermediate - duration LAs - USA Articaine 4% Lidocaine 2% Mepivacaine 2% Drug Onset (textbook) Pulpal Soft Tissue Epi 1:100k 1:200k 2-3 min 60 min 3-5 hours Epi 1:50k, 1:100k 3-5 min 60 min 3-5 hours Levonordefrin 1:20k 3-5 min 60 min 3-5 hours How long does it REALLY take for pulpal anesthesia to develop? Prilocaine 4% Epi 1:200k 3-5 min 60 min 3-8 hours Epi = Epinephrine (Adrenalin) 30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer) 10 Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006) 30 Minute Time Course for IANB Soft Tissue Analgesia (sharp dental explorer) 10 Lai, et al, OOOOE, Vol 102, No 4, P 462-68 (2006) 9 8 9 8 85 % 7 70 % Lidocaine#IANB#Mean# 7 Lidocaine#IANB#Mean# 3 1 25 % At 4 minutes: 70% soft tissue numb 25% pulpal anesthesia Lai,#et#al,#so>#?ssue#v.#EPT# 3 1 40 % At 6 minutes: 85% soft tissue numb 40% pulpal anesthesia Lai,#et#al,#so>#?ssue#v.#EPT#
10 9 8 7 3 1 #Kanaa#(2006)(m)(L)# #Nist#(1992)(m)(L)# #Chaney#(1991)(m)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(m)(L)# #Childers#(1996)(m)(L)# #Dagher#(1997)(m)(L)# #Goldberg#(2008)(m)(L)# #Goodman#(2006)(m)(L)# #Hannan#(1999)(1m)(L)# #Hannan#(1999)(2m)(L)# #Steinkruger#(2006)(m)(L)# #Willet#(2008)(m)(L)# #Vreeland#(1989)(m)(L)# #Kanaa#(2006)(p)(L)# #Chaney#(1991)(p)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(p)(L)# #Dagher#(1997)(p)(L)# #Goldberg#(2008)(p)(L)# #Goodman#(2006)(p)(L)# #Hannan#(1999)(p)(L)# #Willet#(2008)(p)(L)# N = 1078 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Average for 28 PRP Studies - 1078 Subjects (1991-2008) with Lidocaine IANB Mean 10 9 8 7 Most doctors wait ~10 minutes N = 1078 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Average for 28 PRP Studies - 1078 Subjects (1991-2008) with Lidocaine IANB Mean 10 9 8 7 Many Some practitioners doctors wait 15 ~15 minutes minutes (67%) Lidocaine#IANB#Mean# Lidocaine#IANB#Mean# 3 1 At 10 minutes: 60% pulpal anesthesia 3 1 At 15 minutes: 67% pulpal anesthesia IANB: Lidocaine + epinephrine % clinically effective pulpal anesthesia 25 % at 4 minutes 40 % at 6 minutes 60 % at 10 minutes 67 % at 15 minutes 95 % at 45 minutes Can we speed the onset of anesthesia... with Articaine?
10 9 8 7 3 1 #Kanaa#(2006)(m)(L)# #Nist#(1992)(m)(L)# #Chaney#(1991)(m)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(m)(L)# #Childers#(1996)(m)(L)# #Dagher#(1997)(m)(L)# #Goldberg#(2008)(m)(L)# #Goodman#(2006)(m)(L)# #Hannan#(1999)(1m)(L)# #Hannan#(1999)(2m)(L)# #Steinkruger#(2006)(m)(L)# #Willet#(2008)(m)(L)# #Vreeland#(1989)(m)(L)# #Kanaa#(2006)(p)(L)# #Chaney#(1991)(p)(L)# #Hinckley#(1991)(m)(L)# #McLean#(1993)(p)(L)# #Dagher#(1997)(p)(L)# #Goldberg#(2008)(p)(L)# #Goodman#(2006)(p)(L)# #Hannan#(1999)(p)(L)# #Willet#(2008)(p)(L)# N = 222 Articaine Lidocaine N = 1078 30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine 10 9 8 7 3 1 + epinephrine Ar/caine#IANB#Mean# Lidocaine#IANB#Mean# Can we speed the onset of anesthesia with Articaine? NO 2015 Dr. Stanley F. Malamed 30-Minute Time Course, Pulpal Analgesia, IANB, Lidocaine, Articaine Buffered Lidocaine 10 9 8 Ar/caine#IANB#Mean# Can we speed the onset of anesthesia... by buffering the LA solution? 67% N = 18 7 3 1 BUFFERED lidocaine + epinephrine Lidocaine#IANB#Mean# #Buffered#Lido#IANB# 2014 2015 Dr. Stanley F. Malamed 2014 2015 Dr. Stanley F. Malamed All 2013 Rights Dr. Stanley Reserved F. Malamed
Can we speed the onset of anesthesia by buffering the solution? YES The local anesthetic ON SWITCH Buffered Local Anesthetics Alkalinized Local Anesthetics 2015 Dr. Stanley F. Malamed Pain Control Options Buffered Lidocaine by IANB By INCREASING the ph of the local anesthetic solution from 3.5 to 7.35 we: Make the injection more comfortable Increase the effectiveness of the LA Dramatically decrease the onset time Decrease postoperative soreness
Summary Clinical Trial Data 6:37 1:51 Malamed SF, Hersh E, Poorsattar S, Falkel M. Faster onset and more comfortable injection with 2014 Dr. Stanley F. Malamed alkalinized 2% lidocaine with epinephrine 1:100,000. Compendium 34:(spec issue #1):1-11, 2013 2014 Dr. Stanley F. Malamed FDA Approved for Lidocaine HCl Lidocaine 2% + epinephrine 1:100,000 = ph 3.5 BUFFERED Lidocaine 1.75% + epi 1:125,000 + CO2 + NaHCO3 = ph 7.4 More dilute 6,000x more active ions to enter nerve Onset treatment recommendations 1. Administer buffered lidocaine IANB 2. DO NOT LEAVE PATIENT!!! 3. You will know if your block is successful in 2 minutes 4. Check for pulpal anesthesia: EPT or Endo-Ice 5. In 2 minutes following IANB begin tooth preparation
Onset clinical treatment recommendations for CEREC preparation 1. Administer buffered lidocaine IANB 2. Scan tooth, if needed (~30 seconds with Omnicam) 3. In 2 minutes following IANB begin tooth preparation 4. Preparation requires 30 to 40 minutes 5. Rescan tooth 6. Patient remains in chair during milling process 7. Completed crown is seated Pain Control Options Articaine Ultracain Septocaine Articadent Vivacaine Septanest Alphacaine Zorcaine Synthesized in Germany 1973 Introduced Germany 1976 Articaine 4% with epinephrine 1:100,000 1:200,000 1st & only Local anesthetic designed for dentistry 2015 Dr. Stanley F. Malamed
Articaine 4% Epinephrine 1:100,000 & 200,000 Buccal infiltration - 100,000 200,000 Duration of pulpal anesthesia (infiltration) = 60 minutes Duration of pulpal anesthesia (nerve block) = 60 minutes 1. As sole injection by mandibular infiltration 2. As a supplement to lidocaine IANB Duration of soft tissue anesthesia = 3-5 hours Buccal infiltration - As sole injection by mandibular infiltration Buccal infiltration - Mandibular infiltration John Meechan (UK) Al Reader (USA)
2014 Dr. Stanley F. Malamed Mandibular Incisors HCl JADA 138(8):1104-1112, 2007 Pulp test every 3 min SUCCESS = 80/80 on 2 consecutive tests Articaine Lidocaine Mandibular 2 nd Molar 75% 45% Mandibular 1 st Molar 87% 57% Mandibular 2 nd Premolar 92% 67% Mandibular 1 st Premolar 86% 61% p value for all: >.0001 Meechan & Ledvinka 1.0 ml Articaine 1:100k BUCCAL infiltration @ lateral incisor: Central incisor: 94% Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002 2014 Dr. Stanley F. Malamed All 2013 Rights Dr. Reserved Stanley F. Malamed Meechan & Ledvinka Mandibular Incisors HCl Mandibular Incisors Articaine B&L 1.0 ml Articaine 1:100k BUCCAL & LINGUAL infiltration @ lateral incisor: Central incisor: 97% Lidocaine B Articaine B Lidocaine B&L Meechan JG, Ledvinka JI. Pulpal anesthesia for mandibular central incisor teeth: a comparison 2014 Dr. Stanley F. Malamed of infiltration and intraligamentary injections. Int Endod J 35:629-634, 2002 All 2013 Rights Dr. Reserved Stanley F. Malamed 2014 Dr. Stanley F. Malamed All 2013 Rights Dr. Reserved Stanley F. Malamed
Buccal infiltration - Advantages 1. Profound pulpal anesthesia 2. 30 to 40 minute duration of plural anesthesia 3. Minimal accessory soft tissue anesthesia Tongue Buccal infiltration - Disadvantage I can t think of any, unless it doesn t work! Pain Control Options Articaine infiltration as a supplement to IANB Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42:238-246, 2009 2014 Dr. Stanley F. Malamed
2013 Dr. Stanley F. Malamed Kanaa JM, Whitworth JM, Corbett IP, Meechan JG Articaine buccal infiltration enhances the effectiveness of lidocaine inferior alveolar nerve block. Int Endodont J 42:238-246, 2009 IANB s at each of 2 visits = 2% lidocaine + epi 1:80K One visit = 4% articaine + epi 1:100K infiltration buccal fold 1st molar (2.0 ml) One visit = dummy injection buccal fold 1st molar Articaine infiltration as a supplement to IANB 1 st Molar 91.7 % 55.6 % Pulp test for 45 minutes 2014 Dr. Stanley F. Malamed Articaine infiltration as a supplement to IANB 1 st Premolar Articaine infiltration as a supplement to IANB Lateral Incisor 88.9 % 77.8 % 66.7 % 19.4 %
Local Anesthesia for the Cerec Appointment malamed@usc.edu Maxillary 1. Buffered lidocaine 2. Infiltration 3. Nerve block: PSA MSA ASA AMSA Mandibular 1. Buffered lidocaine 2. Articaine infiltration 3. Lidocaine IANB + articaine buccal infiltration Thank you for listening...