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continuing education course number 123 local anesthesia reversal authored by stanley f malamed dds uponsuccessful completion of this ce activity 2 ce credit hours may be awarded apeer reviewed ceactivity ...

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                                                                                                                   Continuing Education
                                                                                                                                 Course Number: 123
                                                                             Local Anesthesia
                                                                                                                            Reversal
                                                                                           Authored by Stanley F. Malamed, DDS
                                    Uponsuccessful completion of this CE activity 2 CE credit hours may be awarded
                            APeer-Reviewed CEActivity by
                                                                                                                                    Approved PACE Program Provider
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                                                                                                                                  Continuing Education
                                                     RecommendationsforFluorideVarnishUseinCariesManagement
           LocalAnesthesiaReversal                                                         hydrogen chloride (HCl) in 1948 led to an explosion of new
                                                                                           drugs that have provided the dentist and dental patient with
                                                                                           the opportunity to experience both pain-free treatment and
           LEARNINGOBJECTIVES                                                              a pain-free post-treatment period. However, many patients
           AFTERREADINGTHISARTICLE,THEINDIVIDUAL                                           complain that lingering numbness of residual soft-tissue
           WILL LEARN:                                                                     anesthesia (STA) following completion of a dental
                                                                                           procedure is inconvenient, uncomfortable, and can lead to
            •   Thetypesoflocal anesthesia and mechanisms of action                        soft-tissue injury due to the inability to detect pain,
            •   The clinical use of a new agent that reverses soft                         especially in children.
                tissue anesthesia.                                                              This article reviews the types of LA and mechanisms of
                                                                                           action, and discusses a new agent that reverses STA.
           ABOUTTHEAUTHOR                                                                       The LA armamentarium today consists of drugs
                                  Dr. Malamed is a professor of anesthesia                 providing a range of durations of pain control, from short-
                                  andmedicine at the School of Dentistry at                acting drugs (~30 minutes pulpal anesthesia) to long-acting
                                  the University of Southern California. He                drugs providing pulpal anesthesia up to 7 hours and STA of
                                                                                                                        1
                                  graduated from New York University                       upto12hours’duration. Short-durationdrugsprovidepulpal
                                  College of Dentistry in 1969. He then                    anesthesia for approximately 30 minutes and include
                                  completed a dental internship and                        mepivacaine HCl 3% and prilocaine HCl 4%. The long-
           residency in anesthesiology at Montefiore Hospital and                          duration category consists of bupivacaine HCl 0.5% with
           Medical Center in the Bronx, NY before serving for 2 years                      epinephrine 1:200,000, providing pulpal anesthesia for up to
           in the US Army Dental Corps at Ft.Knox, Kentucky.In 1973,                       7 hours (commonly from 90 to 180 minutes) with STA for up
           hejoined the faculty of the University of Southern California                   to 12 hours. Interestingly, bupivacaine HCl is a long-acting
           School of Dentistry (Los Angeles) where today he is a                           anesthetic when administered by nerve block (NB) (eg,
           professor of anesthesia and medicine. He is also a                              inferior alveolar NB) only. It is not nearly as long acting when
           Diplomate of the American Dental Board of Anesthesiology.                       administered by supraperiosteal (infiltration) injection.
           He has authored more than 120 scientific papers and 16                               Astheusuallengthofdentaltreatmentisapproximately
           chapters in various medical and dental journals and                             44 minutes, the short-duration anesthetics fail to meet the
                                                                                                                                         2
           textbooks in the areas of physical evaluation, emergency                        pain control needs of many patients.
           medicine, local anesthesia, sedation, and general anesthesia.                        The intermediate-duration category is most often used.
           He authored the textbooks Handbook of Local Anesthesia                          With the inclusion of a vasopressor (epinephrine or
           (5th ed.), Emergency Medicine in Dentistry (6th ed.), and                       levonordefrin [in the US]), the drugs in this group provide
           Sedation: A Guide to Patient Management (4th ed.). He can                       pulpal anesthesia of approximately 60 minutes’ duration.
           be reached at (213) 740-1081 or malamed@usc.edu.                                Intermediate-duration drugs include articaine HCl 4% with
                                                                                           epinephrine 1:100,000 and 1:200,000; lidocaine HCl 2% with
           Disclosure: Dr. Malamed is a paid consultant for Novalar                        epinephrine 1:50,000 and 1:100,000; mepivacaine HCl 2%
           Pharmaceuticals, Inc.                                                           with levonordefrin 1:20,000 (with epinephrine 1:100,000 in
                                                                                           Canada);and prilocaine HCl 4% with epinephrine 1:200,000.
           INTRODUCTION                                                                    Table 1 summarizes these drugs based upon expected
                                                                                           duration of pulpal anesthesia.
           Local anesthesia (LA) forms the backbone of pain control                             It is pulpal anesthesia that allows the doctor to
           techniques in dentistry. The introduction of lidocaine                          painlessly treat the tooth. Anesthesia of the associated soft
                                                                                        1
                                                                                                                 Continuing Education
                                                                                                  Local Anesthesia Reversal
         tissues occurs hand-in-hand with pulpal anesthesia.                  usually limited to nerve blocks (inferior alveolar [Gow-
         Though necessary for many treatments such as curettage,              Gates]), large areas of STA develop along with the desired
         periodontal surgery, extractions, implants, and subgingival          pulpal anesthesia.The anterior two thirds of the tongue, the
         tooth preparation, in order for these procedures to be               lower lip, and cheek are left without sensation for many
         completed painlessly, the duration of STA is of considerably         hours following completion of dental treatment.
         longer duration than that of pulpal anesthesia, averaging 3 to            Recently, new techniques (actually the reinvention of very
         5 hours in the intermediate-duration group of LAs (Table 1).         old techniques) have been introduced which provide localized
              Another factor determining not just the duration of             areasofpulpalanesthesiawithaminimumofassociatedSTA.
         anesthesia but its extent is the choice of local anesthetic          These include the periodontal ligament (PDL) injection (also
                                                                                                                                   3
         technique. For example, following a maxillary infiltration           known as the intraligamentary injection (ILI)          and the
                                                                                                      4
         over the lateral incisor, the tooth will be anesthetized (pulpal     intraosseous injection.   Anesthesia of the tongue or lip is
         anesthesia) along with the localized soft tissues in that            essentially nonexistent following these injections.
         area, such as those in the buccal fold and the lip. Following
         the anterior superior alveolar nerve block a large area on           RESIDUALSTA
         the anterior portion of the maxilla, including the lower eyelid
         to the lateral border of the nose to the upper lip extending         The long duration of residual STA may be desirable
         from the midline to the corner of the mouth on that side, will       following some dental treatments; examples include
         beanesthetized.                                                      surgical procedures (oral surgical, periodontal, and
              In the mandible, where anesthesia in the adult is               endodontic). However, most operative dental care requires
           Table 1. Expected Durations of Pulpal and SoftTissue Anesthesia (STA)
                                             Vasopressor                  Pulpal anesthesia (minutes)           STA (minutes)
            SHORT-DURATION
            Mepivacaine hydrogen             None                         20to30(infiltration)                   90to120
            chloride (HCl)                                                30to45(nerveblock)
            Prilocaine HCl                   None                         10to15(infiltration)                   60to120(infiltration)
                                                                          45to65(nerveblock)                    120to240(nerveblock)
            INTERMEDIATE-DURATION
            Articaine HCl                    1:100,000                    60(infiltration)                       180to240
                                             1:200,000                    up to 120 (nerve block)
            Lidocaine HCl                    1:50,000                     55to65(infiltration)                   180to300
                                             1:100,000                    80to90(nerveblock)
            Mepivacaine HCl                  1:20,000 levonordefrin       40to60(infiltration)                   180to300
                                                                          60to90(nerveblock)
            Prilocaine HCl                   1:200,000                    35to45(infiltration)                   180to480
                                                                          50to70(nerveblock)
            LONG-DURATION
            Bupivacaine HCl                  1:200,000                    Upto7hours(infiltration)               240to720
                                                                          Upto7hours(nerve block)
            Sources: Malamed SF. Handbook of local anesthesia. 5th edition. St. Louis, Mo: CV Mosby; 2003;79 and Malamed SF,Yagiela JA.Pain Control in Dentistry. ADA News.
            September 2007 (supplement).
                                                                            2
                                                                                                                      Continuing Education
                                                                                                       Local Anesthesia Reversal
          profound anesthesia (pulpal) during the relatively brief
          treatment period while the patient is in the dental chair.
          Once treatment is completed there is no longer a need for
          continued anesthesia of the tissues, either hard or soft.
          However, the need for effective intraoperative pain control                                                       Figure 1.
          normally mandates the use of LA containing a vasopressor                                                          Soft-tissue injury
          such as epinephrine or levonordefrin, which has become                                                            following inferior
          a routine part of dentistry.5,6 Patients are commonly                                                             alveolar nerve block.
          discharged from the dental office with residual numbness to
                                                                           7
          their lips and tongue, typically persisting for 3 to 5 hours.            Table 2. Incidence of Lip Injury
              Residual STA presents as an inconvenience or                         Following Inferior Alveolar Nerve Block
          embarrassment to the patient who is unable to function
          normally for many hours after leaving the dental                          Age (years)            %with soft tissue injury to lip
                                                              8
          appointment. In a survey by Rafique, et al             of patients
          receiving intraoral LA, the authors stated that there were                <4                                   18
          several aspects of the post-LA experience that were                       4to7                                 16
          disliked by patients, including 3 major areas—functional,                 8to11                                13
          sensory, and perceptual.
              Functionally, the patients disliked their diminished                  >12                                  7
          ability to speak (lisping), to smile (asymmetric), to drink               Source: College C, Feigal R, Wandera A, Strange M. Bilateral versus
          (liquid runs from the mouth), and the inability to control                unilateral mandibular block anesthesia in a pediatric population.
          drooling while still numb. Sensorially, the lack of sensation             Pediatr Dent. 2000;22:453-457.
          was described as quite discomforting, while the perception
          that their body was distorted (eg, swollen lips) was equally
          unpleasant. For many patients these sequelae become a                   hurts, and then test the still-numb side—which doesn’t hurt.
          significant detriment to their quality of life, making it difficult     Where the adult would normally not proceed beyond this
          for them to return to their usual activities for hours after            point, the younger child may “play” with this “feeling” and
          treatment. When the dental appointment concludes at a                   continue to bite ever harder and harder, not realizing the
          time approaching a meal, either lunch or dinner, patients               damage that is being inflicted. Mentally handicapped adults
          must consider whether to eat while numb or postpone their               are just as likely to incur self-inflicted soft-tissue injury. This
          dining until the residual STA resolves.                                 author was surprised to learn from dentists who treat geriatric
              Though not normally a significant problem, residual STA             patients that another group—the geriatric patient with
          may occasionally lead to self-inflicted injury in any patient.          dementia—presents a risk of soft-tissue injury following LA
          Self-inflicted injury to soft tissues—most commonly the lip or          injection equal to or greater than that of children and mentally
          tongue—is more apt to be noted in younger children and in               challenged adults.
                                                                         1,9
          mentally disabled adult and pediatric patients (Figure 1).
                                                                  9
              A study of pediatric patients by College, et al revealed            HOWLASWORK—ANOVERVIEW
          that a significant percentage of inferior alveolar nerve
          blocks were associated with inadvertent biting of the lips. By          In a simplistic description of how LAs work to block nerve
          age group, the frequency of trauma to the lips was 18% (< 4             conduction and prevent pain, consider a dynamite stick and
          years), 16% (4 to 7 years), 13% (8 to 11 years), and 7% (> 12           a fuse (Figure 2). The dynamite stick represents the brain
          years) (Table 2). This can be explained by the fact that the            (central nervous system); the fuse the peripheral nerve, for
          younger patient will test (by biting) their un-numb lip—which           example the inferior alveolar nerve. When the fuse is lit
                                                                               3
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