Stabident
  intraosseous anesthesia delivery system

DOSAGE TO USE

As with the administration of all drugs, the minimum dose possible should be given. Clinicians should always be mindful of the toxic effects of local anesthetic overdose and be prepared to cope with any emergency that may arise. One half or three quarters of a 1.8ml cartridge, or one cartridge in the case of “hot teeth”, is in most cases adequate to give deep pulpal anesthesia. NEVER EXCEED an aggregate dosage of two cartridges per patient per visit.

Duration of Anesthesia
As with intraligamentary injections, the duration of anesthesia using the Stabident System is shorter than with infiltration or mandibular block injections. The Stabident System will provide pulpal anesthesia for 15 – 45 minutes. The duration of anesthesia will vary depending on the solution used, being slightly longer if a solution containing a vasoconstrictor is used. If more than two areas of the mouth are being operated on during the same visit, then it is advisable to anesthetize one area, carry out the preparatory work, insert lining/s and then move on to the next area and so on.
In the event that sensitivity begins to return to a tooth after approximately 15 minutes and before a procedure has been completed, the anesthesia will diminish gradually. If further anesthesia is required, a small amount of the local anesthetic solution remaining in the original 1.8ml cartridge can be used, by simply re-inserting the needle into the perforation and re-injecting, a 30 second procedure.

Vasoconstrictors
( Note For a fuller account of effects of adrenergic agents, see final section).

It is essentially a matter of personal preference as to whether or not to use an anesthetic containing a vasoconstrictor for Stabident injections. Many doctors do prefer to use a vasoconstrictor-containing anesthetic, but on the other hand many others choose to use a plain anesthetic.
As mentioned above, a somewhat longer duration of anesthesia will be obtained if a solution containing a vasoconstrictor is used. On the other hand, in this case the dentist will need to take into account the transient effects of epinephrine when explaining the procedure to the patient.
Intraosseous injection of anesthetic solutions containing vasoconstrictors (epinephrine and levonordefrin) will result in a transient heart rate increase in the majority of patients. 1-5, 7, 10, 12, 26-27 Patients should be informed of the likelihood of a transient increase in heart rate before receiving intraosseous injections of anesthetic solutions containing vasoconstrictors, to allay anxiety.
The intraosseous injection of 3% mepivicaine plain (Carbocaine) will not result in an increase in heart rate. 27, 6 Therefore, patients do not need to be informed of an increase in heart rate when receiving intraosseous injections of 3% mepivicaine plain.
While the transient heart rate increase with the Stabident injection of anesthetic solutions containing vasoconstrictors would be noticed by the patient, it would not be clinically significant in most healthy patients. 27 In patients whose medical condition or drug therapies suggest caution in administering epinephrine- or levonordefrin- containing solutions, 3% mepivicaine plain (Carbocaine) would be an alternative for intraosseous injections. 6,11.

Using Stabident in Pediatric Dentistry
Perforation of the cortical plate in younger patients is easier because the cortical bone has not reached maximum calcification.

1. For extractions of upper bicuspids for orthodontic reasons, Stabident will remove the necessity for a palatal injection.
2. In case of upper first molars that have large pulps, open apices, long palatal roots extending palatally, supplementary palatal innervation or a combination of some or all of these, Stabident will succeed where an infiltration may fail.
3. In case of traumatized/fractured anterior teeth, where exposed pulps are difficult to anesthetize with infiltration, Stabident will provide the level of anesthesia required for pulp removal.

The table below indicates maximum safe dosages for children. In most cases however, it will be found that smaller amounts of anesthetic than those shown will provide pulpal anesthesia.

MAXIMUM SAFE PEDIATRIC DOSAGES
BODY WEIGHT
DOSE
(Number of 1.8ml cartridges)
60-80 pounds
1/2
80-100 pounds
2/3
More than 100 pounds
1

CAUTION: Intraosseous injection should not be used in areas of mixed dentition because of the insufficiency of cancellous space and also because of the possibility of damaging a developing tooth crown.

Cardiovascular effects of IO injection of adrenergic agents.
(Note.For an abridged account of this topic, please refer to Vasoconstrictors section.


Various authors 1-5, 7, 10, 12, 26-27 have reported a transient increase in heart rate (46% to 90% of the time) with the Stabident intraosseous injection of epinephrine- and levonordefrin- containing solutions. Replogle et al. 27 and Coggins et al. 1 found 60% and 75% of subjects reported a perceived increase in heart rate (subject questioning) with the Stabident Io injection of 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. Replogie et al. 27 reported 67% of their subjects objectively (electrocardiogram recordings) had an increased heart rate with the Stabident IO injection of 1.8 ml of 2% lidocaine with 1:100,000 epinephrine. The mean increase was 28 beats per minute. Chamberlain et al. 26 found the Stabident IO injection of 2% lidocaine with 1:100,000 epinephrine resulted in a mean heat rate increase of 12 beats per minute. Guglielmo et al. 5 reported that the supplemental Stabident IO injection of 1.8 ml of either 2% lidocaine with 1:100,000 epinephrine or 2% mepivacaine with 1:20,000 levonordefrin resulted in a mean increase in heart rate of 23-24 beats per minute (measured with a pulse oximeter) in 80% of the subjects. There was no significant difference between the two solutions. 5 Stabile et al. 7 found the supplemental IO injection of 1.8 ml of 1.5% etidocaine with 1:200,000 epinephrine resulted in a mean increase in heart rate of 32 beats per minute (measured with a pulse oximeter) in 90% of the subjects. Generally, all these studies showed that the heart rate returned to baseline readings with four minutes in most patients. There is no change in blood pressure when administering intraosseous injection of 2% lidocaine with 1:100,000 epinephrine. 26-27 Therefore, intraosseous injection of anesthetic solutions containing vasoconstrictors would result in a heart rate increase in the majority of patients. The patient should be informed of the likelihood of an increase in heart rate, before receiving intraosseous injections of anesthetic solutions containing vasoconstrictors, to lessen their anxiety.
Replogle et al. 27 and Gallatin et al. 6 showed that the intraosseous injection of 3% mepivacaine plain (Carbocaine) resulted in no significant increase in heart rate. Therefore, patients do not need to be informed of an increase in heart rate when receiving intraosseous injections of 3% mepivacaine plain.
While the heat rate increases with the Stabident injection of anesthetic solutions containing vasoconstrictors would be noticed by the patient, it would not be clinically significant in most healthy patients. 27 Replogle et al. 27 discussed the clinical significance, cardiovascular effects and contraindications to the use of vasoconstrictors in intraosseous injections and the reader is referred to this article for review. In patients whose medical condition or drug therapies suggest caution in administering epinephrine- or levonordefrin- containing solutions, 3% mepivacaine would be an alternative for intraosseous injections. 11, 6

REFERENCES

1. Coggins R, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.

2. Dunbar D, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endodon 1996:22:481-6.

3. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W: Anesthetic efficacy of the intraosseous injection of 2% lidocaine (1:100,000 epinephrine) and 3% mepivacaine in mandibular first molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997:83:30-7.


4. Reitz J, Reader A, Nist R, Beck M, Weaver J: Anesthetic efficacy of the intraosseous injection of 0.9 ml of 2% lidocaine (1:100,000 epinephrine) to augment an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:516-23.

5. Guglielmo A, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2% mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93.

6. Gallatin E, Stabile P, Reader A, Nist R, Beck M: Anesthetic efficacy and heart rate effects of the intraosseous injection of 3% mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7

7. Stabile P, Reader A, Gallatin E, Beck M, Weaver J: Anesthetic efficacy and heart rate effects of the intraosseous injection of 1.5% etidocaine (1:200,000 epinephrine) after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:407-11.

8. Gallatin J, Reader A, Nusstein J, Beck M, Weaver J: A comparison of two intraosseous anesthetic techniques in mandibular posterior teeth. J Am Dent Assoc 2002, Accepted for publication.

9. Gallatin J, Nusstein J,, Reader A, Beck M, Weaver J: A comparison of injection pain and postoperative pain of two intraosseous anesthetic techniques. Anes Prog 2002; Accepted for publication.

10. Reitz J, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy of a repeated intraosseous injection given 30 min following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1999;45:143-149.

11. Reisman D, Reader A, Nist R, Beck M, Weaver J : Anesthetic efficacy of the supplemental intraosseous injection of 3% mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82

12. Nusstein J, Reader A, Nist R, Beck M, Meyers W: Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endodon 1998;24:487-491.

13. Ingle J, Bakland L: Endodontics, 5th edition, BC Decker, Hamilton, Ontario 2002;p 391.

14. Wood M, Reader A, Nusstein JM, Beck M, Padgett D, Weaver J: Venous blood concentrations of lidocaine after maxillary infiltration and intraosseous injection. J Endodon 2002;28:237 (abstract).

15. Wood M. A comparison of the anesthetic efficacy of intraosseous and infiltration anesthesia. Master Thesis 2001, The Ohio State University.

16. Hull TE, Rothwell BR: Intraosseous anesthesia comparing lidocaine and etidocaine. J Dent Res 1998;77:197 (abstract).

17. Parente SA, Anderson RW, Herman WW, Kimbrough WF, Weller RN. Anesthetic efficacy of the supplemental intraosseous injection for teeth with irreversible pulpitis. J Endodon 1998;24:826-8

18. Daniellsson K, Evers H, Nordenram A: Long-acting local anesthetic in oral surgery: an experimental evaluation of bupivacaine and etidocaine for oral infiltration anesthesia. Anesth Prog 1985: March/April;65-8.

19. Gross R, Reader A, Becks M, Meyers W: : Anesthetic efficacy of lidocaine and bupivacaine in human maxillary infiltrations. J Endodon 1988;14:193 (abstract).

20. Bacsik CJ, Swift JQ, Hargreaves KM: Toxic systematic reactions of bupivacaine and etidocaine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:18-23.

21. Schleder J, Reader A, Beck M, Meyers W: The periodontal ligament injection: A comparison of 2% lidocaine, 3% mepivacaine, and 1:100,000 epinephrine to 2% lidocaine with 1:100,000 epinephrine in human mandibular premolars. J endodon 1988;14:397-404.

22. D’Souza J, Walton R, Peterson L: Periodontal ligament injection: An evaluation of extent of anesthesia and postinjection discomfort. J Am Dent Assoc 1987;114:341-4.

23. Donohue D, Garcia-Godoy F, King DL, Barnwell GM. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ACDC J Dent Child 1993;60:104-6.

24. Oulis CJ, Vadiakas GP, Vasilopoulou A. The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children. Pediatr Dent 1996;18:301-5.

25. Sharaf AA. Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ASDC L Dent Child 1997;64:276-81.

26. Chamberlain TM, Davis RD, Murchison DF, Hansen SR, Richardson BW: Systemic effects of an intraosseous injection of 2% lidocaine with 1:100,000 epinephrine. General Dent 2000:May-June:299-302.

27. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers W: Cardiovascular effects of intraosseous injection of 2 % lidocaine with 1:100,000 epinephrine and 3% mepivacaine. J Am Dent Assoc 1999;130:649-57

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