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Mandibular Infiltration in Adults

Providing effective pain control is one of the most important aspects of dental care. Indeed, patients rate a dentist who does not hurt and one who can give painless injections as meeting the second and first most important criteria used in evaluating dentists. 44 Unfortunately, the ability to attain consistently profound anesthesia for dental procedures in the mandible of adult patients has proved extremely elusive. This is even more of a problem when infected teeth are involved, primarily mandibular molars. Anesthesia of maxillary teeth on the other hand, although on occasion difficult to achieve, is rarely an insurmountable problem. Reasons for this, as discussed in Chapter 12, include the fact that the cortical plate of bone overlying the maxillary teeth is normally thin, thus allowing the local anesthetic drug to diffuse when administered by supraperiosteal injection (infiltration). Additionally, relatively simple nerve blocks, such as the PSA, MSA, ASA (infraorbital), and AMSA, are available as alternatives to infiltration. Maxillary anesthesia technique was discussed in Chapter 13. It is commonly stated that the significantly higher failure rate for mandibular anesthesia is related to the thickness of the cortical plate of bone in the adult mandible. Indeed it is generally acknowledged that mandibular infiltration is successful where the patient has a full primary dentition (see discussion of pediatric local anesthesia in Chapter 16). 45, 46 Once a mixed dentition develops, it is a general rule of teaching that the mandibular cortical plate of bone has thickened to the degree that infiltration might not be effective, leading to the recommendation that mandibular block techniques should now be employed. 47 A second difficulty with the traditional Halsted approach to the inferior alveolar nerve (e.g., IANB, mandibular block) is the absence of consistent landmarks. Multiple authors have described numerous approaches to this oftentimes elusive nerve. 48- 50 Reported failure rates for the IANB are commonly high, ranging from 31% and 41% in mandibular second and first molars to 42%, 38%, and 46% in second and first premolars and canines, respectively, 51 and 81% in lateral incisors. 52 Not only is the inferior alveolar nerve elusive, studies using ultrasound 53 and radiography 54, 55 to accurately locate the inferior alveolar neurovascular bundle or the mandibular foramen revealed that accurate needle Nerves on the outside of the nerve bundle supply the molar teeth, while nerves on the inside (core fibers) supply the incisor teeth. Therefore the local anesthetic solution deposited near the IAN may diffuse and

block the outermost fibers but not those located more centrally, leading to incomplete mandibular anesthesia. This difficulty in achieving mandibular anesthesia has led to the development of alternative techniques to the traditional (Halsted approach) inferior alveolar nerve block. These have included the GowGates mandibular nerve block, the Akinosi-Vazirani closed-mouth nerve block, the periodontal ligament (PDL, intraligamentary) injection, intraosseous anesthesia, and, most recently, buffered local anesthetics. 59 Although all maintain some advantages over the traditional Halsted approach, none is without its own faults and contraindications. The ability to provide localized areas of anesthesia by infiltration injection without the need for nerve block injections has a number of benefits. Meechan 60 has enumerated them as follows: (1) technically simple, (2) more comfortable for patients, (3) can provide hemostasis when needed, (4) in many cases obviate the presence of collateral innervation, (5) avoid the risk of potential damage to nerve trunks, (6) lesser risk of intravascular injection, (7) safer in patients with clotting disorders, (8) reduce risk of needlestick injury, and (9) preinjection application of topical anesthetic masks needle penetration discomfort. Attempts at mandibular infiltration in adult patients have been made in the past. In a 1976 study of 331 subjects receiving IANB with lidocaine HCl 2% with epinephrine 1:80,000, 23.7% had unsuccessful anesthesia. 61 Supplemental infiltration of 1.0 mL of the same drug on the buccal aspect of the mandible proved successful in 70 of the 79 failures. Of the remaining 9, 7 were successfully anesthetized following additional infiltration of 1.0 mL on the lingual aspect of the mandible. Yonchak and colleagues investigated infiltration on incisors, reporting 45% success following labial infiltration (lidocaine 2% with 1:100,000 epinephrine) and 50% success with lingual infiltrations of the same solution for lateral incisors, and 63% and 47% for central incisors on labial and lingual infiltration. 62 Meechan and Ledvinka found similar success rates (50%) on central incisor teeth following labial or lingual infiltration of 1.0 mL of lidocaine 2% with 1:80,000 epinephrine. 63 In 1990, Haas and coworkers compared mandibular buccal infiltrations for canines with prilocaine HCl versus articaine HCl and found no significant differences. 64 Success rates were 50% for prilocaine and 65% for articaine (both 4% with epinephrine 1:200,000). A second study noted a 63% success rate on mandibular second molars with articaine and 53% with prilocaine (both 4% with epinephrine 1:200,000).

Since the introduction of articaine HCl 4% with epinephrine 1:100,000 into the U.S. dental market in June 2000, numerous anecdotal reports have been received from doctors who claimed that they no longer needed to administer the IANB to work painlessly in the adult mandible. They claimed that mandibular infiltration with articaine HCl was uniformly successful. These claims were initially met with skepticism. In the past 5 years, four well-designed clinical trials have been reported comparing infiltration in the adult mandible of articaine HCl 4% with epinephrine 1:100,000 versus lidocaine 2% with epinephrine 1:100,000 or 1:80,000. 7, 8, 52, 66

Duration of Pulpal Anesthesia

The maximum duration of anesthesia possible in this trial was 43 minutes. The duration of pulpal anesthesia was significantly longer for first molars and first premolars but not for lateral incisors (see previous chart).

IANB injection supplemented with articaine by buccal infiltration was more successful than IANB alone for pulpal anesthesia in mandibular teeth. Articaine infiltration increased the duration of pulpal anesthesia in premolar and molar teeth when given in combination with a lidocaine IANB and produced a more rapid onset for premolars. These four clinical trials clearly demonstrate that articaine given by mandibular buccal infiltration in the mucobuccal fold by the first mandibular molar can provide more successful anesthesia of longer duration to mandibular teeth when administered alone or as a supplement to IANB. One thing to consider is that in each of these trials, buccal infiltration of articaine was administered adjacent to the first mandibular molar. These trials demonstrated the effectiveness of articaine in improving pulpal anesthesia success rates in molars and premolars. However, success rates and duration of anesthesia were not improved as significantly in lateral incisorsteeth at a distance from the site of local anesthetic deposition. Meechan JG, Ledvinka JI: Pulpal anaesthesia for mandibular central incisor teeth: a comparison of infiltration and intraligamentary injections, Int Endod J 35:629634, 2002. 63 In 2002, Meechan and Ledvinka studied the effect of infiltrating 1.0 mL of 2% lidocaine with 1:80,000 epinephrine buccally or lingually to the mandibular central incisor. 63 A success rate of 50% was achieved with the buccal or lingual injection site. However, when the injection

dose was split (0.5 mL per site) between buccal AND lingual, the success rate increased to a statistically significant 92%. Jaber A, Al-Baqshi B, Whitworth B, et al: The efficacy of infiltration anesthesia for adult mandibular incisors, J Dent Res 88:Special Issue A (Abstract 702), 2009. 74 Jaber and colleagues used a split dose (0.9 mL per site) of 2% lidocaine with 1:100,000 epinephrine to confirm this finding. 74 For buccal infiltration of 1.8 mL alone, successful anesthesia of the central incisor was 77% vs. 97% for the split buccal/lingual dose. Investigators also compared articaine 4% with epinephrine 1:100,000 versus lidocaine 2% with epinephrine 1:100,000 as an anesthetic for infiltration in the anterior mandible and found that articaine was superior to lidocaine in obtaining pulpal anesthesia of the central incisor when infiltrated adjacent to the tooth buccally alone (94%) or with split buccal/lingual injections (97%). The increased success rate for infiltration in the adult mandibular incisor region is thought to be due to the fact that the cortical plate of bone, both buccal and lingual, is thin and might provide little resistance to infiltration.

Summary and Conclusions

Failure rates for profound pulpal anesthesia following the traditional inferior alveolar nerve block (IANB) on nonpulpally involved teeth are quite high. This has led to the development of several alternative techniques, including the Gow-Gates mandibular nerve block, the Akinosi-Vazirani closed-mouth mandibular nerve block, periodontal ligament injection, and intraosseous anesthesia. The introduction of articaine HCl spurred interest in its use by infiltration in the adult mandible. Initial studies infiltrating articaine in the buccal fold adjacent to the first mandibular molar showed significantly greater success rates compared with lidocaine 2% infiltration (all with epinephrine). Additional studies using articaine mandibular infiltration (by the first molar) as a supplement to IANB (with lidocaine or articaine) demonstrated the same significant increases. In each of these studies, a full cartridge of local anesthetic was administered (1.8 mL [USA] or 2.2 mL [UK]). Further research is needed to determine the minimal volume of LA solution needed to produce the best clinical result. At this time, the recommendation is to administer a full cartridge of articaine 4% with epinephrine 1:100,000 (or 1:200,000) in the mucobuccal fold adjacent to the mandibular first molar when treating molars or premolars in the adult mandible.