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Intraosseous injection
DENTAL P R O D U C T
(510[k]) and the CE mark. (The CE mark is the official marking required by the European Community for all electric and electronic equipment that will be sold or put into service for the first time anywhere in the European Community. It proves to the buyer, or user, that the product fulfills all essential safety and environmental requirements as they are defined in the socalled European Directives. CE marked products are presumed to conform with the requirements of Directives and as such can be supplied anywhere in the European Community without further testing.) 1. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93.
Intraosseous injection Successful anesthesia during dental procedures can be difficult to achieve. Intraosseous injection has been shown to enhance anesthetic success significantly when used alone1-3 or as a supplement to conventional local anesthetic, particularly in cases of irreversible pulpitis.4-9 Anesthesia of the surrounding soft tissue, bone and teeth is achieved by the deposition of local anesthetic into the vascular spaces of the alveolar cancellous bone. EFFICACY When used alone, intraosseous injection of 1.8 milliliters 2 percent lidocaine with 1:100,000 epinephrine was shown to be 90 percent effective for anesthetizing maxillary molars and 75 percent effective for mandibular molars.2,9,10 As a supplemental injection, intraosseous deposition of 2 percent lidocaine with 1:100,000 epinephrine was 90 percent effective.8 Lip numbness reportedly is attenuated with intraosseous injection10 and tongue and cheek numbness reportedly do not occur.3 The onset of anesthesia is immediate, and the duration is from 15 to 30 minutes, depending on the presence of vasoconstrictors.2,10 All the clinical studies that evaluated the efficacy of intraosseous injections used the Stabident system.1-18 CARDIOVASCULAR EFFECTS Intraosseous injection of local anesthetic solutions containing vasoconstrictors (2 percent lidocaine with 1:100,000 epinephrine) caused a transient increase in heart rate in a majority of patients, but had no effect on blood pressure.1,4 The average increase was about 25 beats per minute and occurred during solution deposi-
SPOTLIGHT
2. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487-91. 3. Gallatin E, Stabile P, Reader A, Nist R, Beck M. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3 percent mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7. 4. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998;45:143-9. 5. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 6. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6. 7. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.
tion or within two minutes after solution deposition. The heart rate returned to normal within four minutes. The authors stated that this effect would not be clinically significant in most patients, but patients should be informed of the possible increase in heart rate to lessen their anxiety. In patients whose medical condition or therapeutic regimens contraindicate the use of epinephrine- or levonordefrin-containing solutions, mepivacaine can be used as an alternative anesthetic.1,4 INDICATIONS Primary intraosseous injections are useful for short procedures and for lessening the feeling of numbness.9 However, intraosseous injections are most useful for enhancing the efficacy and duration of anesthesia achieved by conventional methods, particularly in refractory cases.9 CONTRAINDICATIONS Intraosseous injections may be contraindicated in patients with severe periodontal disease or acute infection, a narrow zone of attached gingiva and crowded teeth.9,11 INFECTION No studies have evaluated the effect of intraosseous injection on gingiva and bone, but Dunbar and colleagues8 have found no incidence of infection after these injections. Coggins and colleagues10 found that 1.25 percent of the subjects (two of 160) required antibiotic administration owing to swelling and purulence at the injection site. Within 14 days, the sites had healed. MARKETED DEVICES There are three devices marketed for intraosseous injection: the Stabident System (see Dental Product Spotlight), Hypo Brand Intraosseous Needle (MPL Technologies, Franklin Park, Ill., “www.dentsply.com/ divisions/mpl.html”) and The IntraFlow Dental Anes-
JADA, Vol. 133, July 2002 Copyright ©2002 American Dental Association. All rights reserved.
983
DENTAL P R O D U C T
SPOTLIGHT
thesia System (IntraVantage Inc., Plymouth, Minn., “www.intraflow.com”). ■ 1. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ. Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. JADA 1999;130: 649-57. 2. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ. Anesthetic efficacy of the intraosseous injection of 2 percent lidocaine (1:100,000 epinephrine) and 3 percent mepivacaine in mandibular first molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83: 30-7. 3. Leonard MS. The efficacy of an intraosseous injection system of delivering local anesthetic. JADA 1995;126:81-6. 4. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93. 5. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24: 487-91. 6. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998;45:143-9. 7. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 8. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6.
984
9. Brown R. Intraosseous anesthesia: a review. J Calif Dent Assoc 1999;27:785-92. 10. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41. 11. Coury KA. Achieving profound anesthesia using the intraosseous technique. Tex Dent J 1997;114:34-9. 12. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93. 13. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487-91. 14. Gallatin E, Stabile P, Reader A, Nist R, Beck M. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3 percent mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7. 15. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998; 45:143-9. 16. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 17. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6. 18. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.
JADA, Vol. 133, July 2002 Copyright ©2002 American Dental Association. All rights reserved.
(510[k]) and the CE mark. (The CE mark is the official marking required by the European Community for all electric and electronic equipment that will be sold or put into service for the first time anywhere in the European Community. It proves to the buyer, or user, that the product fulfills all essential safety and environmental requirements as they are defined in the socalled European Directives. CE marked products are presumed to conform with the requirements of Directives and as such can be supplied anywhere in the European Community without further testing.) 1. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93.
Intraosseous injection Successful anesthesia during dental procedures can be difficult to achieve. Intraosseous injection has been shown to enhance anesthetic success significantly when used alone1-3 or as a supplement to conventional local anesthetic, particularly in cases of irreversible pulpitis.4-9 Anesthesia of the surrounding soft tissue, bone and teeth is achieved by the deposition of local anesthetic into the vascular spaces of the alveolar cancellous bone. EFFICACY When used alone, intraosseous injection of 1.8 milliliters 2 percent lidocaine with 1:100,000 epinephrine was shown to be 90 percent effective for anesthetizing maxillary molars and 75 percent effective for mandibular molars.2,9,10 As a supplemental injection, intraosseous deposition of 2 percent lidocaine with 1:100,000 epinephrine was 90 percent effective.8 Lip numbness reportedly is attenuated with intraosseous injection10 and tongue and cheek numbness reportedly do not occur.3 The onset of anesthesia is immediate, and the duration is from 15 to 30 minutes, depending on the presence of vasoconstrictors.2,10 All the clinical studies that evaluated the efficacy of intraosseous injections used the Stabident system.1-18 CARDIOVASCULAR EFFECTS Intraosseous injection of local anesthetic solutions containing vasoconstrictors (2 percent lidocaine with 1:100,000 epinephrine) caused a transient increase in heart rate in a majority of patients, but had no effect on blood pressure.1,4 The average increase was about 25 beats per minute and occurred during solution deposi-
SPOTLIGHT
2. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487-91. 3. Gallatin E, Stabile P, Reader A, Nist R, Beck M. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3 percent mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7. 4. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998;45:143-9. 5. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 6. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6. 7. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.
tion or within two minutes after solution deposition. The heart rate returned to normal within four minutes. The authors stated that this effect would not be clinically significant in most patients, but patients should be informed of the possible increase in heart rate to lessen their anxiety. In patients whose medical condition or therapeutic regimens contraindicate the use of epinephrine- or levonordefrin-containing solutions, mepivacaine can be used as an alternative anesthetic.1,4 INDICATIONS Primary intraosseous injections are useful for short procedures and for lessening the feeling of numbness.9 However, intraosseous injections are most useful for enhancing the efficacy and duration of anesthesia achieved by conventional methods, particularly in refractory cases.9 CONTRAINDICATIONS Intraosseous injections may be contraindicated in patients with severe periodontal disease or acute infection, a narrow zone of attached gingiva and crowded teeth.9,11 INFECTION No studies have evaluated the effect of intraosseous injection on gingiva and bone, but Dunbar and colleagues8 have found no incidence of infection after these injections. Coggins and colleagues10 found that 1.25 percent of the subjects (two of 160) required antibiotic administration owing to swelling and purulence at the injection site. Within 14 days, the sites had healed. MARKETED DEVICES There are three devices marketed for intraosseous injection: the Stabident System (see Dental Product Spotlight), Hypo Brand Intraosseous Needle (MPL Technologies, Franklin Park, Ill., “www.dentsply.com/ divisions/mpl.html”) and The IntraFlow Dental Anes-
JADA, Vol. 133, July 2002 Copyright ©2002 American Dental Association. All rights reserved.
983
DENTAL P R O D U C T
SPOTLIGHT
thesia System (IntraVantage Inc., Plymouth, Minn., “www.intraflow.com”). ■ 1. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ. Cardiovascular effects of intraosseous injections of 2 percent lidocaine with 1:100,000 epinephrine and 3 percent mepivacaine. JADA 1999;130: 649-57. 2. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ. Anesthetic efficacy of the intraosseous injection of 2 percent lidocaine (1:100,000 epinephrine) and 3 percent mepivacaine in mandibular first molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83: 30-7. 3. Leonard MS. The efficacy of an intraosseous injection system of delivering local anesthetic. JADA 1995;126:81-6. 4. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93. 5. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24: 487-91. 6. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998;45:143-9. 7. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 8. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6.
984
9. Brown R. Intraosseous anesthesia: a review. J Calif Dent Assoc 1999;27:785-92. 10. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41. 11. Coury KA. Achieving profound anesthesia using the intraosseous technique. Tex Dent J 1997;114:34-9. 12. Guglielmo A, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy and heart rate effects of the supplemental intraosseous injection of 2 percent mepivacaine with 1:20,000 levonordefrin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:284-93. 13. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the supplemental intraosseous injection of 2 percent lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 1998;24:487-91. 14. Gallatin E, Stabile P, Reader A, Nist R, Beck M. Anesthetic efficacy and heart rate effects of the intraosseous injection of 3 percent mepivacaine after an inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:83-7. 15. Reitz J, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of a repeated intraosseous infection given 30 min. following an inferior alveolar nerve block/intraosseous injection. Anesth Prog 1998; 45:143-9. 16. Reisman D, Reader A, Nist R, Beck M, Weaver J. Anesthetic efficacy of the supplemental intraosseous injection of 3 percent mepivacaine in irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:676-82. 17. Dunbar D, Reader A, Nist R, Beck M, Meyers W. Anesthetic efficacy of the intraosseous injection after an inferior alveolar nerve block. J Endod 1996;22:481-6. 18. Coggins R, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficacy of the intraosseous injection in maxillary and mandibular teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:634-41.
JADA, Vol. 133, July 2002 Copyright ©2002 American Dental Association. All rights reserved.