A good inferior alveolar injection technique puts the needle very near the nerve. The nerve runs the risk of being traumatized by the needle because obviously the dentist can't see the nerve. How are dentists supposed to perform this injection without risking hitting the nerve?

I have never heard that Septocaine is 22 times more likely to cause damage. I would like to read that article if somebody could tell me which journal to find it in. As an aside, I have found that it works well in people who otherwise are extremely difficult to get numb.

Additionally, I have given two patients numbness that has lasted more than a day (one was a family member). It wore off in a day with one patient, and in a few weeks with my family member (only the tongue was affected). In both cases the anesthetic used was a 2% lidocaine solution.

Working on patients who are not numb, even those who say they will tough it out, is tremendously difficult (they wiggle, flinch, and want the dentist to hurry up), and usually the quality of work is compromised; in fact, sometimes an untimely flinch could even cause a pulp exposure in the tooth, and a root canal may be necessary.

Patients have the final say on whether they want to get an injection or not. Dentists have the final say as to whether they will treat that patient or not.

My dad is a dentist and he has not had any patients with permanent nerve damage. He uses traditional techniques.

What do patients expect for informed consent. Obviously if we went through every risk with every patient prior to every procedure, we wouldn't get anything done. On the other hand if the dentist just tells the patient to "open wide" then the patient can't make an informed decision. No matter how good a dentist is, bad things sometimes happen, some more frequently than others. It is remotely possible that a person could die from a strange reaction to an anesthetic. How frequent should an adverse reaction be for you to feel that a dentist should inform you that it is a possibility? 1 in 100? 1 in 10,000? 1 in a million? Just wondering.

I'll appreciate any feedback.

So, what can dentists realstically do? Have concern enough to warn patients about potential and rare risks. Secondly, show even more concern when a rare complication occurs. I'd say more than half the people on these boards are more upset that their dentists just blew them off after the injury, rather than the actual injury. Educate yourself on treatments, educate the patient, and hope for the best.

P.S. As for the 20% higher risk of Septocaine (articaine) there has been much speculation about it, as well as an article published on PubMed. You can get to it through the main page of this site under links and just search for it. However, all other reviews I have read claim that articaine is perfectly safe and poses no higher risks. There are also wonderfully technical articles about injection techniques that reduce nerve risk on PubMed. Happy searching.

Best of luck in your practice

Just a simple "there can be some serious risk involved" and lay it out. Let us decide. he told me he might have a "little problem getting out the one tooth" and lo and behold that is the injured side. If I had known the serious risks I would have delayed the one tooth but old buddy boy wouldn't get to charge me would he. He knew that he was going to have a "little problem" but what the hell, that extra 500 bucks would make his car pament and I was a willing NAIVE VICTIM.

FOR GOD'S SAKE. JUST BE HONEST!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

If you injure a patient learn how to help them heal and be compassionate and send them to the proper doctors asap. Acknowledge them. I don't think my oral surgeon knows the first thing about healing an injury. He told me to saok my mouth with hot (tea or coffe hot) water twenty times a day for 3 months. What do you think that did to my healing process. My neurologist thinks I have an enlarged nerve. Hot water? On an injury? For 3 months? think about it. No wonder the nerve is enlarged. I kept searing it daily. You do not do that to an injury!!!! I was stupid to listen to him. He sent me away and when I asked for a second opinion he said no and I went back to my dentist who reffered me the dentist said that my oral surgeon had doubt about my pain level. 2400mg neurontin! which I had to obtain after I found this site and realised there is help and medication and HEALING. without this site...I don't know. My doctor should have been there for me but he knew his arse was covered and didn't give a rat's ass.
And by the way, thank you for caring enough to ask. I think you are going to be a great dentist.
CT

In short however, if you notice anything unusual about an injection, stop, withdraw slowly and go in from a different angle. I think you can hit a nerve without destroying it, but if you inject the anesthesia, that could further damage it.

Don't attempt extractions close to nerves and sinuses, refer them to an OS (and even they can screw up).

If you do damage a nerve, refer to an OS or neurologist within 2-3 weeks.

It's a good sgn that you are even here to see the other side of the story.

I did sign a disclaimer, with the attitude, "These things never really happen, he's just covering his ass." Was I ever surprised!

Last week I had crown prep procedure done on my left bottom rear molar. The dentist I've been going to is a butcher. He has always given painful injections, and I should have changed years ago, but inertia set in, and I don't often need treatment. This time he pressure-fed lidocaine with what felt like an elephant-sized needle. It hurt like holy hell, and I groaned louder than in childbirth. It still wasn't numb, so we went through a slightly less painful repeat injection in mid-procedure. Now my left tongue is numb. }:-<

Thanks to this site, I will definitely call my PCP tomorrow and ask for a referral to an appropriate oral surgeon, and do whatever is needed to find one at the local dental school. AND, I will find another dentist, who realizes the risks, and has more finesse.

What can you do? 1) Master the technique of mini-pain shots, as my endodontist has done. 2) Encourage patients to delay non-critical treatment, i.e., that extra wisdom tooth. Chances are it never would have erupted or caused problems if it hadn't by then. 3) Learn all you can and make appropriate referrals.

Last of all, send me your address. Perhaps you can be my new dentist.

Its sad we have to have a site like this but there is good being done here. New dent, in regards to your question...in all honesty there are some things we can do. 1. inform ALL patients of potential risk of nerve damage from anesthetics. 2. Let all patients make the choice to be numb or not (believe it or not I have several who choose not to be numbed and they usually know best, I've even done molar extraction without numbing, although I sure don't recommend that one for most patients.) 3.Use as little anesth. as possible, give it plenty of time to work, I usually wait at least 10 min before beginning on a lower block and usually end up giving just one injection. 4. Inject slowly (up to a minute) enter and withdraw slowly. 5. If the patient shows any signs of a pinch/shock effect withdraw fully and reposition (after calming the patient down and assesing the situation of course) 6. Use blocks only when needed, there is some good info for providers on DentalTown regarding technique for pdl's, I find I never block for premolars now. Hopefully this may help. I've been out for 6 years now and thankfully have not had any incidence, although I do feel even with the best of technique, it remains a risk. I would like to see more studies on articaine, it is definatly a great help for many patients who have had trouble getting numb before and I find I give less injections and use less anesthetic (volume wise) on patients. I, along with many other dentists, feel that in most cases technique may be a key factor with this drug (injeting to rapidly being the most common concern) God bless you all and for those who do suffer I pray for you a Full recovery in God's name.

Thanks for checking out this site, and reading the posts.

I had 4 wisdom teeth out on 10/23/02 and have had many of the problems that everyone on the site describes, and I'm still waiting for improvement.

What can you do as a dentist? After my surgery when it became apparent that I was having problems, my OS was very vague about what was wrong. In fact, anything I know about what is wrong with me, I have learned from my own research and this site. He still has not mentioned to me the names of the nerves that might be damaged. He says to wait and it should improve, but he hasn't told me if what I am feeling is "normal" for this condition or not, and he has not told me what the future options could be for me. I feel like he just wants me and my problem to go away, after all, there's no more money in it for him. I feel helpless to do anything, and I suppose, so does he.

So, my advice to you is to care when your patients have problems, and to be up front and honest with them. Maybe even direct them to a site like this before they have work done, so that they are informed consumers of your services. If I had seen this site before my surgery, I probably would not have done it, or at least then I could have asked my OS more informed questions.

Good luck in your practice, I hope you never damage anyone.

I think the first thing to do is to let every pateint know about the risks of the injections. The idea of permanent severe pain and numbness and loss of taste is something that should be disclosed so each patient can make an informed decision.
I have been given over a dozen injections in my lifetime, by 4 dentists, and had never once been told of this potentially crippling risk.

so, number one is let the patients know about the risk.

number 2, let them know that if they do want the injection, to let you know with a hand signal, etc, if they feel the sharp pain of the nerve being nicked. If this is set up befor hand it can eliminate any anesthetic being pumped near or in the nerve.
When I felt the sharp pain, I just thought the denstist had grazed my tongue with the needle. If I would have known and signaled, there wouldn't have been the large injection that followed.

number 3, strongly consider alternatives.
http://www.sciential.net/alternatives_to_anesthesia_for_dent.htm

also, I don't know if another alternative might be to have the patient knocked out, but not anesthetized (sp?) this might work, might not, just an idea

Personally, if I were a dentist, and wanted to do my job as well as I could, which would mean eliminating if possible this risk of nerve damamge, it would also eliminate lawsuit risk, as some patients might seek legal means if they suffer permanent pain and numbness. Minimizing the risk to patients, would also mean minimizing risks to oneself.

And 4th, share the information with other dentists.

It'd be nice if discussing nerve damamge risk with patients became customary in dentistry.

Jon

I am one of those patients that is harder to get numb. I told my dentist about this before hand and also told him what seemed to work with me. I told him that my previous dentist gave me more than the usual amount through several injections. I also told him that he needed to wait a little longer than he normally would before he started. He was in a hurry so what he did instead, and what makes me very angry is that he used what he called a stronger medication and a longer needle. He did not tell me of the difficulties sometimes associated with the medication. Nor did he tell me he was using a longer needle until he was already injecting and I then immediately felt the searing pain and electric shock all the way to my chin. I jumped and informed him of the tremendous pain I was feeling and had felt instantly. His response was, yes it hurts and he did not tell patients this as they tensed up and went on to give me further injections. He either did not know he had hit a nerve or did not seem to care.

So, in response to your comment, it is important for dentists to take time with their patients to tell them what it feels like to hit a nerve and to raise their hand if this has occured so that the dentist does not inject. I have not had one dentist ever mention this to me. I would also like dentists to give complete and full information for any procedure with injections that does not follow rountine and what the patient has had done before. I would not have consented to a longer needle ever and I was very worried about the stronger medication he told me he was using while he was putting the needle in my mouth. This was not informed consent and now I have nerve problems that I could have prevented by saying no to the non-standard procedure he was using. I would have asked him to stick with what I knew worked for me.

Eleine

As for honest informed consent, you raise some objections to doing procedures without local anesthetic, however some dentists are able to do quite a few of their patients without local anesthetic if they are willing. Talking with patients in Europe, in some places no anesthetic seems to be the standard and the patient has to request it if they want it. I do not think that the dentists need to work on some one wiggling around and making things difficult, but if a procedure can be done without local anesthetic and if you are not willing to offer that option, you need to make that clear. You can refuse to do the procedure, but you should not misrepresent that some dentists do the procedure wiithout anesthesia. In my case, I went over 20 years without anesthesia for procedures up to 3/4 crowns and never moved a so much as a hair during the procedures. I would ask each time if thie procedure could be done without anesthesia. When I needed a crown and asked this question, I was told "no". When my lingual nerve was hit, I tried to signal the dentist to withdraw, but he insisted that everything is fine, just relax. He also told me after my sensation did not recover not to worry, everybody recovers. I am out three years now with a very painful lingual neuropathy and a new dentist --- recommended because he has done root canals on people without anesthesia. If I had known that crowns are commonly done without it, I would have known to insist on it, but the fact is it was my first crown, and dental procedures are not something I discussed with people prior to my injury. Just be honest with your patients, if you are concerned about them moving and what that might do, fine, tell them, but don't exaggerate. Is there any data that the countries that use much less local anesthesia have a higher rate of some complication because of that. I suspect that the answer is no, but have not looked. I would be interested if there is...

Secondly, technique. Injury to these nerves are signficant, and as the oral surgeons who have studied them can tell you, most patients do poorly. Although dentists do this procedure all of the time, they should respect that it can cause significant morbidity and on occasion mortality. There is at least on text that I have on the procedure that recommends removing the needle if the nerve is hit, however if you have not setup hand signals or other methods of communication before hand, there is no way to accomplish this. I know at least on ENT physician who has seen enough of these injuries and knows how poorly they do that when he goes to the dentist he actually injects the area himself prior to going, so that if he feels the nerve being hit, he can withdraw. The average dentist considers the risks so low that they just continue as if everything will be fine. I have also seen that many dentists use needle gauges that are smaller than recommended. The oral surgeons who have to dig these out of patient when they break once or twice a year tell me that this is an unnecessary complcation. There are several studies that show that patients cannot tell the difference between the recommended guages and the smaller gauges, but the smaller ones break off more often. Anatomically this is not a good area to have to dig though looking for a needle. Use a 25 gauge at the smallest (and remember that larger gauge numbers are smaller needle diameters, i.e. do not use a 27 or 28 gauge needle...)

Will this correct all of the injuries, no. Is there anything else that can be done? One of the oral surgeons that I have talked to thought that some of the alternative anesthesias have not been given enough chance to succeed by the dentists. They are listed on the alternatives pages of the web site. Consider offering an alternative or two, even if you have to charge more to cover the time and effort.

Ross

Second, tech

I recently had a botched injection and have the 'numb tongue' thing going right now. I can offer some very good advice similar to others and have some experience (as a patient) to back it up.

I had one instance (prior to the latest filling that I had) several years ago when I was getting a wisdom tooth filled in my lower jaw. My dentist (who I can only describe as an old yankee dentist) hit a nerve while attempting to numb the area. I winced and he promptly withdrew the needle and said he was sorry about that. He re-injected the area and I subsequently had no numb tongue or any other after-effects.

For the latest experience replacing the amalgam filling in the wisdom tooth, the dentist gave me multiple injections in the area and when he hit the nerve, I was numb but felt the 'electricity' shoot down the tongue. I didn't wince but all I could do was breath harder and make some sound. The dentist continued, possibly thinking that my reactions were the normal stress from being numbed up. I didn't know that this experience was particularly unusual as I was not informed of any risks whatsoever.

Bottom line -
If it's a tricky injection site (as treating the area of the rear molars on the lower jaw is) let your patients know the risks. Set up the hand signals or whatever. You have a human in your chair remember, not a cadaver. Don't become a 'Dr. Mengala'.

Then,
"First do no harm."

Do those things and you'll do well.

Isn't life great when you get out of school and get to practice? I've read some of the replies and it's also nice when people can provide good advice and keep it on a higher level

I'm online, checking out "burning tongue" for my mother-in-law, and happened on this site. Your comments are more insightful than you may realize. You already sound like the kind of dentist I would like to visit.

I used to hate going to the dentist! A few years ago, I moved to a new community and sought out a local dentist. A friend recommended Dr. Recker (seriously) to me and he has been my dentist ever since. After my recent move (1 hour away), I still make the drive because he's the best! It would take all day to explain why ~ so, if you'd like to visit with him (and give him my regards) he is located in Pella, Iowa.

God Bless!

Rebecca

REGARDS,

GARY BENJAMIN-garybenjamin@cableone.net

1st, I would not have followed the dentist advice to have the wisdom tooth extracted - it was difficult for cleaning & I'd had an infection in it once. I would have not done anything. He'd suggested that I have the other lower one removed too, and it's doing just fine. Plus, that side of my mouth is at least normal.

2nd, If something like this happens I would at least not tell the patient to "not focus so much on it". My oral surgeon basically implied that it was all in my head.

3rd, It's been over 5 years now, and it this damage has changed my life forever. I manage & am lucky that the pain is not consistently intense. But, it would have been nice if the OS would have at least had some compassion.

As far as regular dentist work that requires shots - I try to go with out & can most of the time except for major work. I would really like to see more use of alternative methods like hynosis, etc.

Your message gave me some basic information. I didn't realize that the numbing agent could last so long. Anyway, its just in the last little while that the effect has been diminishing and my full smile is back. What a relief. I once again hold the dental profession in high esteem. Thanks for your post.