Dentaltown April 2018 - 97

continuing
education

*
*
*

Time-saving. No treatment interruption for
additional injections.
Money-saving. No need to buy any additional
armamentarium.
Unstressful. Patients feel confident and relaxed
and they come back to the office.

Adapting the accessory innervation
anesthetic protocol
The AIAP below is flexible in terms that can be
adapted to existing techniques that clinicians are
currently using and familiar with.
The basic AIAP:
* ½ carpule for lingual nerve (short/30-gauge needle).
* 1½ carpules for IAN (long/30-gauge needle).
* ½ carpule for mylohyoid (short/30-gauge needle).
* ½ carpule for buccal (short/30-gauge needle).
* 1 carpule for cervical plexus (short/30-gauge
needle).
* 1 carpule for mental nerve (short/30-gauge needle).
Note that this basic AIAP does not cover the
auriculotemporal nerve, so a small percentage of failure
may occur. If you want to cover this nerve, use the
following AIAP approach:
* 2 carpules Gow-Gates (long/30-gauge needle).
* 1 carpule cervical plexus (short/30-gauge needle).
* 1 carpule mental nerve (short/30-gauge needle).
When I show these approaches to dentists' audiences,
I consistently receive questions about the last injection,
because it's hard to believe the need of a mental nerve
technique after the patient is so numb. The above is indeed
required, because the mental nerve is in a strategically
located anastomosis landmark with the cervical plexus,
incisal and cross line nerves. Not administering the
mental nerve shot after the cervical plexus may result
in inadequate pulpal anesthesia.
If you're not familiar with the Gow-Gates and have
already adopted the intraosseous technique, you can
administer the AIAP as follows:
* ½ carpule for lingual nerve (short/30-gauge needle).
* 1 carpule for IAN (long/30-gauge needle).
* 1 carpule for cervical plexus (short/30-gauge
needle).
* Intraosseous (intraosseous armamentarium).
The main advantage of administering the intraosseous
protocol this way is that the patient will not feel the
intraosseous injection. The intraosseous technique numbs
all the accessory nerves as well and supports the AI theory.

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What if, after all these injections,
the patient still feels pain?
The main reason for this to happen is failure to
get appropriately numb one or more of these nerves.
To find out which nerve has been missed, I like to ask
patients where the pain is traveling to.
* If they say toward the inside, it may be the
lingual or mylohyoid nerves.
* If traveling down to the neck, it may be the CP.
* If it travels toward the ear, it may be the GAN
component of the CP, and a most posterior CP
injection would be required.
* If pain travels up to the head, it may be
the lesser occipital branch of the CP or the
auriculotemporal.
* If the lip is not numb and pain travels the
IAN path, then another IAN injection should
be given.
If you're confident that all these nerves are numb,
just deposit some drops of articaine 4 percent 1:200,000
Epi in the pulp chamber; let it sit for 30 seconds, then
inject directly, instead of the conventional intrapulpal.
The patient may feel a little bit but will not jump out of
the chair, as we would see when the AIAP is not applied.
The anesthetic type varies depending on each patient's
medical history. Because injections are administered
in different locations, you can use different kinds of
anesthetic in the same patient. Typically, I use lidocaine
2 percent with 1:100,000 epinephrine. I have applied
this AIAP with Mepivacaine 3 percent, no epinephrine,
with consistent success. After 45-60 minutes you may
want to reinforce the IAN and lingual, if patient requests
it because of lack of epinephrine. Regarding to the CP:
Because the technique is infiltrative per se, I like to use
Articaine 4 percent with 1:200,000 epinephrine. Thus
far in my clinical experience, no cases of paresthesia
have been reported on this nerve branch.
In terms of timing, the AIAP may take 7-10 minutes
to be completed. At conclusion, there is no need to wait
10 minutes to start working, because you practically
already waited for it. There is no need of revisiting
anesthesia in most of the cases.
Finally, if you have a very large and busy practice and
don't have the time to dedicate to this protocol, my advice
is to hire a hygienist trained to administer anesthetic and
teach her ot him the AIAP to get all your patients numb.
Then you just go and start working with confidence.
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