Anesthesia ineffective on infected roots: advice for extraction?

During the extraction of a mandibular molar, I split the two roots and extracted the distal one without any pain problem. The extraction of the mesial root was very painful to the patient.  The mesial root also had an apical infection with cystic formation.  In discussing this case with colleagues, the consensus is that this is a common problem and local anesthesia is not effective on infected regions.  Is this true?  Do you have any advice for achieving more effective anesthesia in infected areas?

Thanks.



16 thoughts on: Anesthesia ineffective on infected roots: advice for extraction?

  1. Doc says:

    I usually do a Gow Gates or Akinozi – a block of some sort.
    I also find if your LA with epi isn’t working, adding a 4% Carbocaine plain changes the pH and you have a greater chance of better anesthesia.

  2. KPM says:

    Well, unfortunately if we remove teeth we’re going to run into these cases! That being said, if I am having this trouble, after the standard long buccal which I assume you tried first, I will go to the intraligamentary injection (short needle to you can get good pressure downward. Don’t want to use a long that can bend more easily). It can be uncomfortable for the patient but usually by that time it has been bear anyway so to get where you need to go it’s worth it. If I am still having an issue I will go to the Gow-Gates injection. I won’t describe how to do it here as an anatomical diagram is really needed if you are not familiar with it but this usually will do it. If this does not work then unfortunately it turns into “one of those days” and you have to just go in and remove enough bone around the root to get a good hold on it and get it out of there, quick as possible.

  3. Boulcott says:

    Intra osseous is an old technique that works very well with modern application techniques. You can inject LA right by the infected root more accurately than intraligamentsl.

  4. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    It is true that local infection can make it more difficult to obtain local anaesthesia (but not impossible).
    That said, a well placed lower block should work with lignocaine (lidocaine) and adrenaline (epinephrine). If that does not work then the Gow-Gates block is a great “second move”. If you wish to use this technique then you should look up how to do it. However essentially it is the same as a traditional lower block but placed higher than the usual injection point – so your objective is to block the nerve higher than when it enters the ramus.
    If that fails then you can switch to articaine and adrenaline which offers a more profound anaesthesia (for a longer duration). If you have already placed a block as described above, I would be more inclined to use the articaine adjacent to the tooth in question (buccal and lingual).
    Failing that, you could consider either referring to an oral surgeon, or consider a GA, or spin Odontopaste down the canals and let the infection settle over 2-3 weeks – then extract, or as described by others, get to position where you can leverage the root out with luxators or grasp the root with root forceps and then just do what they did 150 years ago. However the latter method is not one i recommend.

  5. Dr adel says:

    I will administer another cartridge of anestitic at the highest level possible by using Gow-gates technique to anestisize all branches of cranial nerve V3.Also I will consider using a high PH anestetic solution ( one without a vasoconstrictor) to help overcome the acidity created by possible infections.

  6. Adam says:

    Not sure if this has been commented on yet but intrapulpal like a hot pulp works then through the apex into the granulation tissue, once removed, then LA into the infected tissue for curettage.

    Just because we are thinking exo, doesn’t mean you can’t think other techniques for different situations.

  7. David Levitt says:

    In these cases I routinely do a Gowe-Gates AND a standard IA block. If there is still a problem use a ligajet or equivalent for intraligamentary anesthesia. Finally invest in the X-tip system for intra-osseous anesthesia (works great for hot endos BTW). If none of that works refer to an OS for general anesthesia! That’s assuming you are not qualified to do GA or deep sedation yourself. If you are qualified to do oral sedation midazolam .5mg/kg (maximum 35 mg) will give profound amnesia in most cases. Onset of 10 minutes and peak effect in 53 minutes. This does require monitoring with a pulse oximeter and the ability to maintain an airway.

  8. Dr. Alex Galo says:

    I’m surprised no one has mentioned not to treat the patient that day if they have severe infection. Put them on antibiotics and see them in 3 days then freezing is much easier. I find if the patient is not completely frozen after 3 blocks, then try PDL right around the tooth.

  9. Admiral518 says:

    I dont want to be the 13th comment. Please someone comment before me. Lol.
    After you give a lower block do you check for lip symptoms? If you dont have them, then your block is off. Try again . Different angle. Reassess where the ramus is and where you imagine the nerve entry is. If theres a “cystic formation” my guess its not the infection but the injection being off. Its when the infection is diffuse in the tissues, swollen etc when locals are more problematic. (Yes buffering’s great if you can). Buccal infiltration with Articaine is very helpful. If you have access to the nerve an intrapulpal injection usually gets it done. And infltrate around the PDL with leftover in the carpule. Always let the patient sit in this situation go do an exam or a round of solitare. Waiting is essential and checkbfor lip symptoms, ask “is this numb”. Lastly if you want to build a reputation and your practice …cause not pain. As previously suggested prescribe an antibiotic. Antiinflamitory and pain meds and wait 1-2 days.

  10. CRS says:

    Okay here’s what I do, regular local IA block test area if painful then antibiotics and return for IVSedation. It’s really about the patient’s comfort and perception. It’s not about Gow Gates which I don’t recommend due to sequela. Way too much oral versed recommended not safe. Not about me it’s about happy safe comfortable patient experience. If you only could hear the patients in my chair telling about their dental extraction adventures with their GPs . Bet they tell their friends but never you. Sometimes it pays to refer most patients appreciate you putting them first.

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