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Local anaesthetics in dentistry: A series

Article  in  South African dental journal. Suid Afrikaanse tandarts tydskrif · February 2017

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Desigar S Moodley
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communication

Local anaesthetics in dentistry:

A series

SADJ February 2017, Vol 72 no 1 p32 - p34

DS Moodley

ABSTRACT
Failure in local anaesthesia in dentistry is not uncommon ACRONYMS
with failure rates ranging approximately between 15% and IANB: inferior alveolar nerve block
30%, especially for the inferior alveolar nerve block (IANB). In SI: supplemental infiltration
fact of all the nerve blocks which may be administered in the
human body the IANB has the highest failure rate (Malamed, may also influence the success of local anaesthesia, fac-
2012). Therefore, the aim of this series of articles is the dis- tors related to the operator.
cuss some of the causes of failure in local anaesthesia and
make recommendations so as to minimize the experience.
Effect of Anatomical Causes for
Current trends like computer controlled local anaesthetic de- Anesthetic Failures
livery, reversal of soft tissue anaesthesia for patient comfort An understanding of the variations in innervation to the
and “needle free” anaesthesia will be discussed. teeth would help improve the dentist’s ability to induce
profound local anaesthesia.6,7 The trigeminal nerve sup-
Introduction plies sensory function to both the maxillary and man-
dibular teeth. The inferior alveolar nerve, a branch of the
In Dentistry, failure of local anaesthetics is not uncommon
posterior division, supplies sensation to all the mandibular
and is in fact a feature of dental practice.1,2 Clinical suc-
teeth on one side as well as to the mucosa of the lower
cess of local anaesthetics ranges roughly between 75%
lip and skin over the chin. However, simply blocking this
and 90 %.1,3,4 The inferior alveolar nerve block records the
nerve through the traditional inferior nerve block does not
highest failure rate compared with all other nerve blocks in
guarantee complete pulpal numbness in 30% of the pa-
the human body.5 Despite the problems in achieving local
tients.8 Using ultrasound-guided technique, Hannan et al.8
anaesthesia in Dentistry, there are few studies that have at-
showed that a direct hit on the nerve does not guarantee
tempted to determine the mechanisms for these failures.3 In
complete pulpal anaesthesia in spite of obtaining 100%
clinical practice incomplete anaesthesia can lead to a pain-
lip numbness. Thus, complete lip numbness does not
ful experience for the patient as well as being a frustrating
necessarily indicate complete pulpal anaesthesia of the
encounter for the clinician, leading to about 10% of cases
mandibular teeth and the accuracy of needle placement is
having to be postponed. An understanding of the reasons
not the primary reason for pulpal anaesthetic failure with
for failure could help to reduce its occurrence. Thus, the
this block. Accessory or supplementary nerve supply to
aim of this article is to discuss some of the possible causes
the mandibular teeth, in addition to that from the inferior
of failure in local anaesthesia in Dentistry and to make rec-
alveolar nerve, may be a plausible explanation for failed
ommendations which may minimize the problem.
anaesthesia in mandibular teeth.9 Only 5.4% of patients
have no accessory canals while the majority (81%) of pa-
Failure of local anaesthetics tients have between two to six accessory canals.10 Gupta
Lack of success in obtaining complete anaesthesia in et al.11 found accessory foramina in the mandible in 94% of
dentistry may be related to anatomical, physiological or their cases. It may seem that having no accessory canals
psychological factors. Anatomical variations at the site of may be an exception as more often accessory canals can
the injection, infection or inflammation at the injection site be found in the mandible. When these accessory canals
and medical or psychological problems with which the transmit nerve fibres, local anaesthesia may fail as these
patient may present, can affect the anaesthetic outcome branches passing through the accessory canals may pro-
(patient related factors). Choice of anaesthetic agents, the vide an “escape pathway” for sensation. In addition to the
use of vasoconstrictors and experience of the operator inferior alveolar nerve in the mandible, the lingual nerve,
the long buccal nerve, the nerve to mylohyoid, the au-
DS Moodley: PhD, MSc, PDD Aesthet. BDS, FICD. Department of
riculotemporal nerve and the cervical nerves have been
Restorative Dentistry, Faculty of Dentistry, University of the Western implicated as possible accessory suppliers of sensation
Cape, Cape Town, South Africa. Private Bag X1, Tygerberg, 7505. to the mandibular teeth.2,12 The auriculotemporal nerve, a
Tel: 021 9373090 E-mail: [email protected]
branch of the anterior division of the mandibular nerve,
www.sada.co.za / SADJ Vol 72 No. 1
communication <
33

premolar, canine and incisor teeth and occasionally the

first mandibular molar.13 The presence of both Ad fibres
(afferent) and Aa fibres (efferent) in this nerve confirms its
Auriculo temporal nerve
mixed nature.14 Studies indicate the mylohyoid nerve as an
alternate ‘‘escape route’’ for pain in the mandibular teeth.12
To overcome accessory innervation from the mylohyoid
Buccal nerve Inferior alveolar nerve nerve, the clinician can deposit anaesthetic solution
higher in the pterygomandibular space or infiltrate on the
Lingual nerve
lingual surface of the mandible adjacent to the tooth3 so
as to block the nerve as it enters the mandible on the
Retromolar
foramina lingual aspect.

In the upper jaw the greater palatine and nasopalatine

nerves may send sensory innervation to the maxillary
teeth in which instance blocking of these nerves by in-
jecting palatally will provide complete anaesthesia to the
Mylohyoid nerve
maxillary teeth.2

Supplemental injections
Retromental foramen
Occasionally traditional techniques of anaesthesia like
infiltration and regional block injections may not provide
successful anaesthesia especially in endodontics for the
so-called inflamed pulp (hot tooth) or irreversible pulpitis.
Figure 1: Diagrammatic representation of accessory nerve supply to the According to the American Association of Endodontics, a
mandible recent systemic review to evaluate the anaesthetic success
rates of the inferior alveolar nerve block (IANB) injection
technique alone or along with supplemental infiltration (SI)
technique when used for pulpal anaesthesia of mandibular
Intraligamental injection
posterior teeth with irreversible pulpitis, indicated that none
of the techniques gave 100% success rate.15 When inferior
alveolar nerve block alone was used only 14-39% success
rate was obtained but when supplemental injections were
included, success was significantly increased to 50-65%
for irreversible pulpitis.15

The term intra-ligamentary or periodontal ligament

Intraosseous injection
anaesthesia may be misleading as the anaesthetic
injected into the periodontal ligament provides pulpal
anaesthesia by penetrating the cancellous bone through
natural perforations (Figure 2). The anaesthetic fluid
spreads along the outer surface of the alveolar plate
and under the periosteum, moving into crestal marrow
spaces along vascular channels and not through the
Figure 2: D
 iagrammatic representation showing intraligamental and
intraosseous injections. periodontium by travelling down the length of the
ligament, as was previously assumed.16,17 Some authors
may send out filaments as it loops around the condyle.13 suggest that placing the bevel of the needle to face the
These may enter the lower jaw through a foramen located alveolar wall increases the efficacy18 while Malamed19
slightly above the mandibular foramen to supply the man- advocates that the bevel should face the root as this
dibular molar teeth (Figure 1). In this instance the dentist allows easier advancement of the needle. It is thus now
will need to inject slightly higher than the traditional inferior recommended to commence with the bevel facing the
alveolar nerve target to be able to block the auriculotem- root to facilitate penetration and then to rotate the needle
poral nerve as well. Foramina present in the retromolar to face the bone to increase efficacy.20 The success rate
region may also provide entry points for filaments of the when periodontal injection is used as a supplement to
long buccal branch of the inferior alveolar nerve supplying conventional IANB is 78%.17
innervation to the mandibular teeth (Figure 1). A long buc-
cal block or mandibular buccal infiltration may be neces- Intra-osseous injection consists of introducing the local
sary for complete anaesthesia in such cases.2 anaesthetic directly into periradicular cancellous bone via
specialized systems like Stabident (Fairfax Dental, USA)
The mylohyoid nerve originates as a small posterior branch and X-Tip (X-Tip Technologies, USA). Success rates for
of the inferior alveolar nerve before the latter enters the conventional inferior alveolar nerve block with supple-
mandibular foramen.12 The branch runs along the mylohyoid mental intraosseous injections ranged from 80% with the
groove on the medial surface of the mandible to supply the first injection and increased to 98% with a second intra-
mylohyoid and the anterior belly of the digastric muscles. osseous injection.21 Intra- osseous injection can provide
Some sensory fibres could enter the mandible through profound anesthesia for 60 minutes when used as a sup-
the retromandibular foramina and provide innervation to plement in cases of failed IANB.17
34 > communication

In approximately 5-10% of mandibular posterior teeth with 21. Reisman, D, Reader, A, Nist, R, Beck, M, Weaver, J. Anaes-
irreversible pulpitis, supplemental injections, even when thetic efficacy of the supplemental intraosseous injection of
repeated, do not produce profound anaesthesia; pain 3% mepivacaine in irreversible pulpitis. Oral Surgery, Oral
persists when the pulp is entered.22 This is an indication Medicine, Oral Pathology, Oral Radiology, and Endodontics
1997 ; 84(6): 676–82.
for an intrapulpal injection. Onset is usually immediate and
no special syringes or needles are required. The disad-
vantage is that the injection is painful.

Conclusion
Accessory nerve supply especially to the mandibular
teeth seems to provide an “escape” route for pain and
may contribute to failed anaesthesia in the dental chair. In
these instances, the dental clinician needs to block these
accessory nerve supplies to ensure complete anaesthesia
for their patients.

References
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