Inferior dental blocks versus infiltration dentistry: is it time for change?

Abstract

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.