Dental Block, ER Doc | Department of Emergency Medicine

Another Solution for Dental Pain when “NSAIDs do nothing for me Doc!

Resident Clinical Pearl (RCP) – Guest Resident Edition

Peter Leighton, R3 FMEM 2+1, Dalhousie University, Halifax

Dental pain is a common problem encountered in the Emergency Department (ED), yet physicians in the ED often have no to little education regarding management of dental pain. Depending on where you read, dental pain complaints account for 1-5% of emergency department visits. A common approach consists of looking for infection and providing a prescription for antibiotics and NSAIDs along with recommendation to follow up with a dentist. Although, there is good evidence for NSAIDs in dental pain, some patients find that it does not help enough with their pain or they have contraindications to NSAIDs. This often leads to the prescription of opioids for dental pain. Given the recent opioid crisis in Canada, there has been a search for other forms of management of toothache/dental pain in the ED. Insert the dental block! It’s fast, easy, and provides good pain relief, while providing a chance for patients to book an appointment to see their dentist the following day. There has been some evidence that this method achieves good pain control for the patient and may help lower opioid prescriptions in the ED for dental pain.

There are essentially 2 blocks you will need to know:

The Inferior Alveolar Nerve Block (Mandibular teeth)
Supraperiosteal Infiltrations (Maxillary teeth)

Indications

Dental abscess
Toothache
Pulpitis
Root impaction
Dry socket
Post-extraction pain
Trauma – lacerations, fractures

Contraindications

Allergy to local anesthetic
Distortion of landmark
Uncooperative patient
Injecting through infected tissue – may cause bacteremia
Cardiac congenital abnormalities and mechanical valves – require prophylaxis for endocarditis
Coagulopathy

What you will need

Syringe
Needle – 25-27 gauge and 1.5 inch
Lidocaine with epinephrine (max dose 7 mg/kg)
Bupivicaine +/- epinephrine (max dose 2 mg/kg)
Non-sterile gloves
Suction and light source may be required

The combination of Lidocaine and Bupivicaine allow the mix of immediate analgesia from the Lidocaine and prolonged duration of action by the Bupivicaine. The addition of Epinephine will also increase duration of effect. This combination should provide approximately 8 or more hours of anesthetic effect.

Technique:

Supraperiosteal Infiltration

Pull out patient’s cheek laterally to have a good view of the patient’s tooth and gingiva. Insert needle into the mucobuccal fold just above the apex of the tooth to be anesthetized. Keep the needle parallel to the tooth and insert it a few millimeters until needle tip is above the apex of the tooth. If bone is contracted, withdraw 1-2mm and aspirate. If no blood is aspirated then inject 1-2 ml of anesthetic. If blood is aspirated then withdraw and reposition.

From: www.ebmedicine.net – click here for full article

***Inferior Alveolar Nerve* *Block***

Place your thumb in the coronoid (mandibular) notch of the patient and extend the patient’s cheek out laterally so you can see the patient’s pterygomandibular raphe. Place your syringe in the opposite corner of the mouth and with your needle at the middle level of the raphe, aim just lateral to the raphe. Insert your needle approx. 2-2.5cm until you hit bone. Pull back a millimeter and aspirate twice. If any blood on aspiration, withdraw and reposition more laterally. If no blood with aspiration then inject 1-2ml of anesthetic.

From: Jason Kim’s Blog – click here for full article