At a recent Facially Generated Treatment Planning workshop, I was having lunch with a group of dentists with a wide range of experience and age–from one year out of school to 20 years of practice. Frustration with the lack of predictable mandibular blocks stimulated a great conversation with a lot of energy. We have all experienced the complication and embarrassment of attempting to finish a crown preparation (Fig. 1), remove deep decay (Fig. 2), or access a pulp chamber with less than profound anesthesia on a lower molar due to a mandibular block. mandibular blockThe participants (and I) were wondering if they were missing something – besides the nerve that they assumed they were missing – that could help them.  Was there something that could prevent a mandibular block? Are there supplemental injections besides the long buccal, mylohyoid, intraosseous, PDL, etc.?

The Infamous Mandibular Block… You Are Not Alone

Having recently transitioned from private practice with similar experiences and subsequently seeing the frustrations of dental students and faculty almost every day, while working with brilliant people who teach anatomy and injection techniques, I thought it might be a good idea to take a fresh look at the current literature regarding the infamous mandibular block. The review sadly revealed that even in 2014, they are not alone with this dilemma that has hindered our profession for so long, and neither are you. Misery loves company, right? We talked about so many reasons that could lead to the variability of results, including the use of Articaine. There is still some hesitation to use Articaine due to years of reports of increased parasthesia with mandibular blocks. Even though it has been shown that the efficacy is statistically better than Lidocaine in several studies, we avoid using it knowing it could predictably help one of our biggest stressors of mandibular dental work. More and more, however, we start to see that our fears are unwarranted.  One fairly recent article documented a well-done meta-analysis demonstrating that, “Articaine is more likely than Lidocaine to achieve an anesthetic success in the posterior first molar area…” and that there is, “no difference in post-injection adverse events or post-injection pain.” 1 In no way do I think that any one article should shape our decision to use Articaine or any other local anesthetic or offer great hope for predictable outcomes for mandibular blocks. However, after a fairly extensive review, I do think that there is sufficient evidence, understanding and there are certain techniques to present to each patient with a variety of options or tools in our tool-belt to dramatically increase our odds, decrease stress and know that we are doing the best we can. It also helps to know that we are not alone or missing something. I will be sharing those articles and findings with you in a subsequent Spear Monthly Digest article. For now, you might just try trusting the research and a new carpule in your syringe before your next mandibular molar procedure.

References:

  1. J Dent. 2010 Apr;38(4):307-17. doi: 10.1016/j.jdent.2009.12.003. Epub 2009 Dec 16.The efficacy and safety of articaine versus lignocaine in dental treatments: a meta-analysis. Katyal V.
 

Comments

Commenter's Profile Image Mark Venditti
October 22nd, 2014
This has been a hot topic in the area I work. The dean of dentistry at the University of Toronto has been a vocal proponent of using lidocaine for mandibular blocks the reasons you discuss.
Commenter's Profile Image Christopher Kemp
October 22nd, 2014
I've used Septocaine for blocks since it was approved by the FDA back in 2000. I have had a half dozen paresthesia events that all recovered over the course of several months. I switched to Septocaine Silver (1:200k epi) after the first couple paresthesia incidents because I had read somewhere that it had a lower incidence of causing problems with Man blocks. I have no idea what the statistics are for these events. I don't know if it's technique, the anesthetic, or just 'the odds' (I was in a busy practice and saw 10-15 patients/day) that caused the problems. I found Septocaine to be much profound than lidocaine for blocks. That being said, I recently switched back to lidocaine and have had really good results... with a twist. I use Onpharma's system of adding Sodium Bicarbonate to your lidocaine carpule. The theory is by adding a base to the acidic anesthetic, you're freeing way more anesthetic molecules to do their job AND it 'mellows out' the anesthetic to reduce the 'burning' sensation some patients experience at the injection site. More Comfortable and More Profound tried and true lidocaine is a good thing. Of course, everything I've said here is empirical. If you're interested in learning more about onpharma, check out the link below. I have no skin in their game. http://www.onpharma.com/
Commenter's Profile Image Kevin Brown
October 25th, 2014
I have used Septocaine for all procedures for10 + years with just 1 incident of paresthesia that resolved. In using lidocaine for 15 years previous I had 2 incidents of short term paresthesia. Dr Malamed has lectured about the statistical difference between lidocaine & articaine resulting in paesthesia as being insignificant. The profound effect of Septocaine for pt comfort , plus the speed of onset far out way the risk of paresthesia.
Commenter's Profile Image Marjorie Lachapelle
November 21st, 2014
I have tried switching to Lidocaine for mandibular blocks instead of Septacaine ( used it for 14 years) and the results are not the same. I couldn't achieve a profound anesthesia and almoat always had to inject a 2nd dose. So I'm back with good old septa and it it's a lot more predictable !
Commenter's Profile Image Jairaj
November 22nd, 2014
In such cases of incomplete anaesthesia there is always a possibility of an innervation from the cervical spinal nerve into the mandibular region , which is an aberration, and hence escapes the local anaesthetic no matter which one is used.
Commenter's Profile Image Dr Osborn
December 6th, 2014
I have been a full time dentist for 33 years. Before 2000, I used lido with good results and had two cases of temporary paresthesia. Since 2000, I have used only Septo with much better results (my patients like it because I rarely need a second injection) and had one case of temporary paresthesia. I think the needle is the cause, not the carpule. I also advance the needle very, very slowly so I don't harpoon any nerve. All reports of increased paresthesia are based on VOLUTARY reports made to malpractice carriers or government agencies so the data is very questionable (I never reported my cases to anyone). I have read of one case in the SOUTH where a dentist blamed paresthesia on the local anesthetic but it was later found out that he was doing endo with SARGENTI paste. This is serious subject and we need solid SCIENCE, not anecdotal stories, to make sound practice decisions.
Commenter's Profile Image Gary Pape
December 31st, 2014
I have also heard conflicting advice regarding the use of septocaine for IA injections. My technique is to use lidocaine for the IA, followed by local infiltration with septocaine. I have found this to be highly successful in achieving profound anaesthesia for lower molars.
Commenter's Profile Image Joe Nolan
December 31st, 2014
Great article Kevin. I've been a dentist for 35 years. I've never used Septocaine. I do a regular mandibular block , a Gow Gates and a long buccal. There is a lot of biological variation in where the nerve exits. If I don't get profound anaesthesia I do a buccal infiltration along the bone lateral to the second molar. I think that gets those pesky cervical nerve fibers. I can almost always can get the person numb.
Commenter's Profile Image Carl Steinberg
January 6th, 2015
I also have suffered for many years with inconsistency in using mandibular blocks for molar anesthesia. Fortunately since 2002 I have not used mandibular blocks and have had predictable results with long buccal and PDL injections using Septocaine and 30 gauge short needles. Carl Steinberg
Commenter's Profile Image Sunoji
May 13th, 2015
I am not a Dentist. Why should a whole quadrant be blocked when working only on one or two molars? Will it be less painful if the solution (Lido or Septo or whatever) is deposited in increments? Say 0.2 mm initially and then more. Thanks!
Commenter's Profile Image Sunoji
May 13th, 2015
Apologies for the typo in my above post, should have been 0.2 cc.
Commenter's Profile Image Wayne Gedutis
May 20th, 2015
Ive been using prilocaine with 1:200,000 for everything, surgery included for the last 40 years and have had only rare occasions where the anesthesia is not profound. Quick onset, profound anesthesia, and as quick return to normal. Just sayin
Commenter's Profile Image Sunoji
May 21st, 2015
@Wayne, I am not sure if you were passing any information to me specifically, but I was more wondering if the bradykinin thingy would not be able to act much if some anesthesia is initially deposited before the needle delves further or sends in more solution. I think patients dont care much if you have another jab as long as the next one is not as painful as the first. (at least I dont, nerve injury is a risk thats part of any invasive procedure, isnt it?) Thanks Anyways!