Dr.

Aneeqa Yaqub

Overview
Understanding the reasons

Operator dependent Patient dependent

Approach to overcome failure Conclusion

Reasons of failure
Operator dependent Choice of solution Poor technique Patient dependent Anatomical Pathological Psychological.

Operator dependent variables

This means:

poor technique Administration of insufficient solution use of an inappropriate anesthetic solution

Choice of solution o The most appropriate local anesthetic solution for most dental procedures is lignocaine with adrenaline o In some medically-compromised patients adrenaline-free solutions may be preferred

 Poor technique: o The most likely defect in technique is faulty needle placement o Failure to aspirate before injection o Speed at which the solution is deposited o Poor technique usually relates to mandibular anesthesia, specifically failed inferior alveolar nerve block injections

Patient Dependent Variables

Anatomical causes of failure of anesthesia o Individual variations in the position of nerves and foramina

Foramina do not have a consistent location between patients Available radiographs may be helpful in anticipating this situation

o Accessory nerve supply Accessory nerve supply can lead to failure of anesthesia following both infiltration and regional block methods

Tooth

Main supply

Accessory supply

Accessory supply countered by: Palatal block or palatal infiltration Long buccal block or buccal infiltration Lingual block or lingual infiltration High block or lingual infiltration High block Buccal and lingual infiltrations

Maxillary Mandibular

Superior alveolar nerve Inferior alveolar nerve

Greater palatine/ Nasopalatine Long buccal nerve

Lingual nerve Mylohyoid nerve Auriculo-temporal nerve Upper cervical nerves

o Barriers to anesthetic diffusion The most obvious barrier is the thick cortical plate of the mandibular alveolus The first molar region in the adult maxilla occasionally presents a similar problem

Pathological causes of failure of anesthesia o Factors precluding access

There is trismus due to

Infection Trauma Anatomical changes due to surgery

It may be prudent to allow the trismus to resolve prior to dental treatment

o Inflammation Teeth with inflamed pulps can be difficult to anaesthetize

How inflammation induces results in failure of anesthesia:

Low pH Wash-out effect Nerves become hyperalgesic

The maximum volume of local anesthetic is given, predetermined safe maximum dose should not be exceeded In patients, where early treatment can be deferred, NSAIDs can be given to reduce inflammation

 Psychological causes of failure

o

There are undoubtedly patients who do not do well with local anesthesia, because of :
Fear Apprehension Drugs

Sedative techniques can be helpful as successful anesthesia is easier to achieve Benzodiazepines offer the added bonus of reducing local anesthetic toxicity

An approach to the failed local anesthetic case

When an initial local anesthetic fails the best

treatment is to repeat the injection

The flow diagrams for management of failure in both

jaws

Maxilla
Buccal Infiltration
Success

Fail Success

Buccal And Palatal Infiltration

Fail

Posterior Superior Alveolar/ Infraorbital Nerve Block

Fail

Success

Intraligamentary/ Intraosseous/ Intrapulpal

Success

Mandible
I.A.N block
success

fail

success

Higher I.A.N block

fail Success

Akinosi block/ GowGates block

Fail

Buccal and lingual infiltration

Intraligamentary/ Intraosseous/ Intrapulpal

success

Conclusion
Failed local anesthesia is a feature of dental practice

Understanding of the reasons for failure, should help

overcome most cases encountered in practice