DOSAGE TO USE
As with the administration
of all drugs, the minimum dose possible should be given. Clinicians
should always be mindful of the toxic effects
of local anesthetic overdose and be prepared to cope with any emergency
that may arise. One half or three quarters of a 1.8ml cartridge, or
one cartridge in the case of “hot teeth”, is in most cases
adequate to give deep pulpal anesthesia. NEVER EXCEED an aggregate
dosage of two
cartridges per patient per visit.
As with intraligamentary injections, the duration of anesthesia using the Stabident
System is shorter than with infiltration or mandibular block injections. The
Stabident System will provide pulpal anesthesia for 15 – 45 minutes.
The duration of anesthesia will vary depending on the solution used, being
slightly longer if a solution containing a vasoconstrictor is used. If more
than two areas of the mouth are being operated on during the same visit, then
it is advisable to anesthetize one area, carry out the preparatory work, insert
lining/s and then move on to the next area and so on.
In the event that sensitivity begins to return to a tooth after approximately
15 minutes and before a procedure has been completed, the anesthesia will diminish
gradually. If further anesthesia is required, a small amount of the local anesthetic
solution remaining in the original 1.8ml cartridge can be used, by simply re-inserting
the needle into the perforation
and re-injecting, a 30 second procedure.
( Note For a fuller account of effects of adrenergic agents, see final
section).
It is essentially a matter of personal preference as to whether or
not to use an anesthetic containing a vasoconstrictor for Stabident
injections. Many doctors do prefer to use a vasoconstrictor-containing
anesthetic, but on the other hand many others choose to use a plain
anesthetic.
As mentioned above, a somewhat longer duration of anesthesia will be obtained
if a solution containing a vasoconstrictor is used. On the other hand, in this
case the dentist will need to take into account the transient effects of epinephrine
when explaining the procedure to the patient.
Intraosseous injection of anesthetic solutions containing vasoconstrictors
(epinephrine and levonordefrin) will result in a transient heart rate increase
in the majority of patients. 1-5, 7, 10, 12, 26-27 Patients should be informed
of the likelihood of a transient increase in heart rate before receiving intraosseous
injections of anesthetic solutions containing vasoconstrictors, to allay anxiety.
The intraosseous injection of 3% mepivicaine plain (Carbocaine) will not result
in an increase in heart rate. 27, 6 Therefore, patients do not need to be informed
of an increase in heart rate when receiving intraosseous injections of 3% mepivicaine
plain.
While the transient heart rate increase with the Stabident injection of anesthetic
solutions containing vasoconstrictors would be noticed by the patient, it would
not be clinically significant in most healthy patients. 27 In patients whose
medical condition or drug therapies suggest caution in administering epinephrine-
or levonordefrin- containing solutions, 3% mepivicaine plain (Carbocaine) would
be an alternative for intraosseous injections. 6,11.
Perforation of the cortical plate in younger patients is easier because
the cortical bone has not reached maximum calcification.
1. For extractions of upper bicuspids for orthodontic reasons, Stabident
will remove the necessity for a palatal injection.
2. In case of upper first molars that have large pulps, open apices,
long palatal roots extending palatally, supplementary palatal innervation
or a combination of some or all of these, Stabident will succeed where
an infiltration may fail.
3. In case of traumatized/fractured anterior teeth, where exposed pulps
are difficult to anesthetize with infiltration, Stabident will provide
the level of anesthesia required for pulp removal.
The table below indicates maximum safe dosages for children. In most
cases however, it will be found that smaller amounts of anesthetic
than those shown will provide pulpal anesthesia.
MAXIMUM SAFE PEDIATRIC DOSAGES |
BODY WEIGHT |
DOSE
(Number of 1.8ml cartridges) |
| 60-80 pounds |
1/2 |
| 80-100 pounds |
2/3 |
| More than 100 pounds |
1 |
CAUTION: Intraosseous injection should not be used in areas of mixed
dentition because of the insufficiency of cancellous space and also
because of the possibility of damaging a developing tooth crown.
(Note.For an abridged account of this topic, please refer to Vasoconstrictors
section.
Various authors 1-5, 7, 10, 12, 26-27 have reported a transient
increase in heart rate (46% to 90% of the time) with the Stabident
intraosseous
injection of epinephrine- and levonordefrin- containing solutions.
Replogle et al. 27 and Coggins et al. 1 found 60% and 75% of subjects
reported a perceived increase in heart rate (subject questioning)
with the Stabident Io injection of 1.8 ml of 2% lidocaine with
1:100,000 epinephrine. Replogie et al. 27 reported 67% of their
subjects objectively
(electrocardiogram recordings) had an increased heart rate with
the Stabident IO injection of 1.8 ml of 2% lidocaine with 1:100,000
epinephrine.
The mean increase was 28 beats per minute. Chamberlain et al. 26 found the Stabident IO injection of 2% lidocaine with 1:100,000
epinephrine resulted in a mean heat rate increase of 12 beats per
minute. Guglielmo
et al. 5 reported that the supplemental Stabident IO injection
of 1.8 ml of either 2% lidocaine with 1:100,000 epinephrine or
2% mepivacaine
with 1:20,000 levonordefrin resulted in a mean increase in heart
rate of 23-24 beats per minute (measured with a pulse oximeter)
in 80% of the subjects. There was no significant difference between
the two solutions. 5 Stabile et al. 7 found the supplemental IO
injection
of 1.8 ml of 1.5% etidocaine with 1:200,000 epinephrine resulted
in a mean increase in heart rate of 32 beats per minute (measured
with a pulse oximeter) in 90% of the subjects. Generally, all these
studies showed that the heart rate returned to baseline readings
with four minutes in most patients. There is no change in blood
pressure when administering intraosseous injection of 2% lidocaine
with 1:100,000
epinephrine. 26-27 Therefore, intraosseous injection of anesthetic
solutions containing vasoconstrictors would result in a heart rate
increase in the majority of patients. The patient should be informed
of the likelihood of an increase in heart rate, before receiving
intraosseous injections of anesthetic solutions containing vasoconstrictors,
to lessen their anxiety.
Replogle et al. 27 and Gallatin et al. 6 showed that the intraosseous
injection of 3% mepivacaine plain (Carbocaine) resulted in no significant
increase in heart rate. Therefore, patients do not need to be informed
of an increase in heart rate when receiving intraosseous injections
of 3% mepivacaine plain.
While the heat rate increases with the Stabident injection of anesthetic
solutions containing vasoconstrictors would be noticed by the patient,
it would not be clinically significant in most healthy patients. 27 Replogle et al. 27 discussed the clinical significance, cardiovascular
effects and contraindications to the use of vasoconstrictors in intraosseous
injections and the reader is referred to this article for review.
In
patients whose medical condition or drug therapies suggest caution
in administering epinephrine- or levonordefrin- containing solutions,
3% mepivacaine would be an alternative for intraosseous injections. 11, 6
1. Coggins R, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy
of the intraosseous injection in maxillary and mandibular teeth. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.
2. Dunbar D, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy
of the intraosseous injection after an inferior alveolar nerve block.
J Endodon 1996:22:481-6.
3. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W: Anesthetic
efficacy 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 1997:83:30-7.
4. Reitz J, Reader A, Nist R, Beck M, Weaver J: Anesthetic efficacy of the
intraosseous injection of 0.9 ml of 2% lidocaine (1:100,000 epinephrine)
to augment an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1998;86:516-23.
5. Guglielmo A, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy
and heart rate effects of the supplemental intraosseous injection of
2% mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;87:284-93.
6. Gallatin E, Stabile P, Reader A, Nist R, Beck M: Anesthetic efficacy
and heart rate effects of the intraosseous injection of 3% mepivacaine
after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2000;89:83-7
7. Stabile P, Reader A, Gallatin E, Beck M, Weaver J: Anesthetic efficacy
and heart rate effects of the intraosseous injection of 1.5% etidocaine
(1:200,000 epinephrine) after an inferior alveolar nerve block. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:407-11.
8. Gallatin J, Reader A, Nusstein J, Beck M, Weaver J: A comparison
of two intraosseous anesthetic techniques in mandibular posterior teeth.
J Am Dent Assoc 2002, Accepted for publication.
9. Gallatin J, Nusstein J,, Reader A, Beck M, Weaver J: A comparison
of injection pain and postoperative pain of two intraosseous anesthetic
techniques. Anes Prog 2002; Accepted for publication.
10. Reitz J, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy
of a repeated intraosseous injection given 30 min following an inferior
alveolar nerve block/intraosseous injection. Anesth Prog 1999;45:143-149.
11. Reisman D, Reader A, Nist R, Beck M, Weaver J : Anesthetic efficacy
of the supplemental intraosseous injection of 3% mepivacaine in irreversible
pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82
12. Nusstein J, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy
of the supplemental intraosseous injection of 2% lidocaine with 1:100,000
epinephrine in irreversible pulpitis. J Endodon 1998;24:487-491.
13. Ingle J, Bakland L: Endodontics, 5th edition, BC Decker, Hamilton,
Ontario 2002;p 391.
14. Wood M, Reader A, Nusstein JM, Beck M, Padgett D, Weaver J: Venous
blood concentrations of lidocaine after maxillary infiltration and
intraosseous injection. J Endodon 2002;28:237 (abstract).
15. Wood M. A comparison of the anesthetic efficacy of intraosseous
and infiltration anesthesia. Master Thesis 2001, The Ohio State University.
16. Hull TE, Rothwell BR: Intraosseous anesthesia comparing lidocaine
and etidocaine. J Dent Res 1998;77:197 (abstract).
17. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic
efficacy of the supplemental intraosseous injection for teeth with
irreversible pulpitis. J Endodon 1998;24:826-8
18. Daniellsson K, Evers H, Nordenram A: Long-acting local anesthetic
in oral surgery: an experimental evaluation of bupivacaine and etidocaine
for oral infiltration anesthesia. Anesth Prog 1985: March/April;65-8.
19. Gross R, Reader A, Becks M, Meyers W: : Anesthetic efficacy of
lidocaine and bupivacaine in human maxillary infiltrations. J Endodon
1988;14:193 (abstract).
20. Bacsik CJ, Swift JQ, Hargreaves KM: Toxic systematic reactions
of bupivacaine and etidocaine. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1995;79:18-23.
21. Schleder J, Reader A, Beck M, Meyers W: The periodontal ligament
injection: A comparison of 2% lidocaine, 3% mepivacaine, and 1:100,000
epinephrine to 2% lidocaine with 1:100,000 epinephrine in human mandibular
premolars. J endodon 1988;14:397-404.
22. D’Souza J, Walton R, Peterson L: Periodontal ligament injection:
An evaluation of extent of anesthesia and postinjection discomfort.
J Am Dent Assoc 1987;114:341-4.
23. Donohue D, Garcia-Godoy F, King DL, Barnwell GM. Evaluation of
mandibular infiltration versus block anesthesia in pediatric dentistry.
ACDC J Dent Child 1993;60:104-6.
24. Oulis CJ, Vadiakas GP, Vasilopoulou A. The effectiveness of mandibular
infiltration compared to mandibular block anesthesia in treating primary
molars in children. Pediatr Dent 1996;18:301-5.
25. Sharaf AA. Evaluation of mandibular infiltration versus block
anesthesia in pediatric dentistry. ASDC L Dent Child 1997;64:276-81.
26. Chamberlain TM, Davis RD, Murchison DF, Hansen SR, Richardson
BW: Systemic effects of an intraosseous injection of 2% lidocaine with
1:100,000 epinephrine. General Dent 2000:May-June:299-302.
27. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W: Cardiovascular
effects of intraosseous injection of 2 % lidocaine with 1:100,000 epinephrine
and 3% mepivacaine. J Am Dent Assoc 1999;130:649-57
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