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Inferior dental blocks versus infiltration dentistry: is it time for change? Tara Renton Dental Update 2024 46:3, 707-709.
Authors
TaraRenton
BDS, MDSc, PhD
Professor of Oral Surgery, King's College London; Honorary Consultant in Oral Surgery, King's College Hospital NHS Foundation Trust and Guy's and St Thomas' NHS Foundation Trust, London
Dentistry is unique in that high volume surgery is undertaken efficiently on conscious patients, an anathema to most other surgical specialties who predominantly operate on unconscious patients. Local anaesthesia provides an efficient block to nociceptive pain (the first stage of the pain pathway) but only addresses one small part of the pain experience. Currently the inferior dental block (IDB) is the ‘go to’ standard for dental LA for mandibular dentistry despite its significant shortcomings. Unfortunately, as creatures of habit clinicians continue to practise what is taught at dental school, namely IDBs, when evolving more patient-safe practice takes time to be taken up by the workforce.
Local anaesthesia blocks are inefficient in providing swift pulpal anaesthesia. Malamed stated that the rate of inadequate anaesthesia ranged from 31% to 81%. When expressed as success rates, this indicates a range of 19% to 69%. These numbers are so wide ranging as to make selection of a standard for rate of success for IDB seemingly impossible. LA blocks also increase the risk of systemic complications and they may be associated with nerve injury. Though LA-related permanent nerve injury is rare (approximately 1in 52–57K IDBs), once the injury occurs approximately 75% may resolve but the remaining 25% are untreatable. Most patients with trigeminal nerve injuries experience chronic pain in their lip, teeth and gums or tongue and gums, depending on which nerve is damaged. This is a lifelong burden that these patients find difficult to accommodate, especially when they were never warned about the possible risk.
The risk of nerve injury can be mitigated by altering the block technique or by avoiding block anaesthesia altogether. With novel development in pharmacology of LA and equipment, block anaesthesia is likely to become rarely needed in dentistry.
CPD/Clinical Relevance: Dentistry is a profession predicated upon causing and/or managing pain in patients. Providing effective pain control during surgery is essential but using techniques with the minimum risks is imperative.
Article
There are five questions that we should first address in critiquing existing LA practice and assess if there is need for improvement.
Proposed tailored smart LA practice:
Patients want two main outcomes when they visit a dental practice, first, pain free injections and second painless procedures.1 However, needles and tablets are but a small part of the holistic pain management of dental patients.2 The definition of pain is that it is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’.3 The brain overlays the pain sensation on the part of the body that is getting hurt to protect it from harm. There are four types of pain:4 two healthy and two pathological. Healthy protective pain includes firstly; nociceptive pain, which is the conversion of tissue injury and release of algogenic factors (intracellular components released due to cell damage) which act as ‘foreign bodies’ exciting pain receptors on nociceptive nerve fibres (C, A delta and A beta fibres). These cause transduction from chemical inflammation into an action potential and the progression of an action potential advancing up to the tertiary order neurones to the somatosensory cortex; once reached, the ‘ouch’ results in reflex withdrawal of the ‘digit’ from danger. Inflammatory pain follows nociceptive pain, if tissue damage occurs promoting tissue healing. This process should usually resolve in days or weeks, depending on the degree of damage and persistence of infection.
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