In this month’s column, I speak with Dr. Alan Budenz - one of my dental school instructors - who has become one of the country’s leading local anesthetic experts. Since local anesthesia is something we tend to take for granted, I thought it would be nice to hear the latest from Dr. Budenz.
Dr. DiTolla: What do you think is the most exciting occurrence in local anesthesia in the last five to 10 years?
Dr. Budenz: To me, the best thing that’s happened in local anesthesia in that time period is the arrival of Septocaine to the U.S. market in 2000. While it’s a good anesthetic, there are drawbacks to it. The simple fact that there is so much controversy about Septocaine has resulted in people asking many questions about anesthetics and how to administer them. Overall, I think this situation is beneficial because people aren’t just taking everything for granted anymore. Typically, people would say, “I use lidocaine for everything except when I can’t use epi, then I use mepivacaine plain. And for long-acting, I use Marcaine.” This has made people think about what’s out there, what’s appropriate to use, what’s safe to use, and what techniques should be used.
Dr. DiTolla: As a 4 percent anesthetic, do you avoid giving blocks with it? There’s some literature about a possible increased rate of paresthesia with Septocaine.
Dr. Budenz: All of the reports I have seen are anecdotal. There has been no scientific study showing absolutely that 4 percent anesthetics are the cause of paresthesia. But there is enough anecdotal material available to make me think there is a greater risk of paresthesia using the 4 percent solutions, both articaine and prilocaine. I am not hesitant to use Septocaine for blocks when it’s indicated, except for the inferior alveolar block. I am extremely hesitant about using Septocaine in this instance because we have seen numerous reports indicating the greatest incidence of paresthesia is with that injection technique and the 4 percent anesthetics.
I don’t choose to give inferior alveolar nerve blocks the conventional way. I prefer the Gow-Gates technique, which from all the evidence I have gathered, is a safer injection with any solution. I use this on a regular basis.
Dr. DiTolla: One of the most frustrating experiences most GPs have is with “hot teeth.” Are there any tips you can give us on accessory innervation and how to anesthetize these patients?
Dr. Budenz: On a mandible, of course, the first nerve to anesthetize is the inferior alveolar nerve while the long buccal nerve is second. The long buccal has been shown to have much accessory innervation to the teeth, particularly the molars. When you look at the retromolar pad area, there are many accessory foramina there. You may wonder if these are for blood vessels, nerves, or just air holes. You cannot tell just by looking at the bone. But there are several holes there. By doing micro-dissection, the long buccal nerve is seen to send little branches into the bone. It’s not just the main pathway as instructors have always taught. There are many accessory nerve branches extending along the long buccal pathway.
Dr. DiTolla: If I were to come to your office and needed crowns on teeth Nos. 18, 19, and 20, explain what you would do in terms of local anesthesia.
Dr. Budenz:I would start with a Gow-Gates injection. It has the best likelihood of anesthetizing the inferior alveolar, the lingual, the long buccal, and the mylohyoid nerves - all with one injection. I would use a 27-gauge needle, and drop a full cartridge of lidocaine. I would use Prilocaine or Septocaine if I knew you were a person who had expressed a history of getting numb but not staying numb long or had a history of drug abuse. In this situation, I might use one of the 4 percent solutions. Ideally, I would just use lidocaine since it is pretty safe. I find that with the Gow-Gates technique, I have a good success rate using one cartridge of lidocaine - in the upper 80 to mid 90 percent range. Occasionally, I need to chase it with a full second cartridge in the same location. The one nerve that is hardest to get to consistently is the long buccal. So sometimes I may have to inject that nerve separately. With a Gow-Gates injection, I have never had to give a separate mylohyoid.
