LOCAL ANALGESIA AND PRIMARY DENTAL CARE

A Clinical Audit into the Success Rate of Inferior Alveolar Nerve Block Analgesia in General Dental Practice
Andrew Keetley and David R Moles

Aims and objectives: The aim of this study was to produce some observational evidence of the success rate of inferior alveolar nerve block (IDB) analgesia that is achieved in general d e n t a l p r a c t i c e. Th e o b j e c t i v e w a s to help provide some measure of expected failure rates and help dental practitioners in their self-appraisal of this crucial basic skill. Method: Up to 100 consecutive IDB analgesia procedures for four dentists were recorded. In a subdivision of this study 200 consecutive IDBs for a fifth dentist were recorded. This dentist had the greatest experience of giving IDB analgesia of the dentists in this study. In this part of the study the dentist made a note if he anticipated that the

procedure would fail. The reason for this was that it was felt that experienced dental practitioners could predict when failure was about to occur. The level of facial nerve palsy was also recorded. Results: Overall, 533 of 580 (91.9%) local anaesthetic administrations were d e e m e d t o b e s u c c e s s f u l . Th e o n l y factor that significantly affected the likelihood of success was the practitioner administering the local anaesthetic, and this was only borderline statistically significant. In order to be certain that the other factors did not a f f e c t t h e o u t c o m e, t h e d a t a w e r e r e - analysed using the technique of Poisson regression. This technique investigated the effects of each of the

factors in turn while controlling for the differences in success that can be attributed to the different practitioners. The regression analyses also did not detect any differences in success that could be attributed to any of the other recorded factors. The incidence of facial palsy was 0.3%. C o n c l u s i o n : Th i s p a p e r g i v e s a n insight into the possible success rates to be encountered by general dental practitioners when they administer IDB analgesia. The only recorded factor that could be shown to affect the chance of a successful local analgesic was the operator. The incidence of facial nerve palsy at 0.3% may be more common than has previously been considered.
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KEY WORDS: CLINICAL AUDIT, INFERIOR ALVEOLAR NERVE BLOCK ANALGESIA, FACIAL NERVE PALSY, GENERAL DENTAL PRACTICE

Introduction
The purpose of this study was to produce some observational evidence of the success rate of inferior alveolar nerve block (IDB) analgesia that is achieved in general dental practice. A recent article in the British Dental Journal 1 referred to IDB analgesia and described how failures could be minimised. Heasman and Beynon 2 also described failure of IDB analgesia citing the following as some of the reasons for failure: Intravascular injection. Unusual local anatomy. Idiosyncratic local analgesic resistant patients.
DA Keetley BDS, DGDP(UK), DPDS. General Dental Practitioner, Kirkhallam Dental Practice, Ilkeston, Derbyshire. DR Moles MSc, BDS, DDPH. Clinical Lecturer and MRC Special Fellow in Health Services Research, Oral Pathology Unit, Eastman Dental Institute for Oral Health Care Science, London.

Accessory innervation to the teeth. A study by Simon et al 3 concluded that administration of anaesthetic injections is a rarely discussed but significant contributor to the overall professional stress for many dentists. However the quoted success rates for dental local analgesic administrations are enormously variable with the range beginning as low as 80%.4-6 Until more evidence of the expected norms of failure are quantified it will be difficult for dentists to assess their own standards of technique in this important area of pain control. There are a number of potential neurological complications of local anaesthetics used in dentistry. These include facial nerve palsy, transient amaurosis, transient paraesthesia and, rarely, transient unilateral deafness. 7 The continuous review of technique by practitioners will help to minimise the risks involved. With the advent of clinical governance in the UK it is now essential that practitioners audit some of their clinical procedures. Publication of results is clearly needed to give some idea of the standards to be expected.
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E C A B

Figure 1 Diagrammatic description of the inferior alveolar nerve block. A : Mandibular ramus. B : Masseter. C : Medial pterygoid. D : Buccal fat pad. E : Superior constrictor of the pharynx F : Buccinator.

pterygomandibular space while the barrel of the syringe is parallel with the occlusal surfaces of the mandibular teeth. Figure 1 describes the anatomy of the region. The aim is detect bone with tactile skill close to the lingula. No attempt was made to influence dentists as to whether they used the indirect or direct method of IDB. The alternative IDB techniques described by Gow-Gates 9 and Akinosi10 were not employed in this study. It is felt that these techniques are not commonly used by general practitioners. The criteria for recording a successful IDB procedure was that the labial attached mucosa between the lower second incisor and the lower canine tooth, on the affected side, should be sufficiently anaesthetised to allow firm probing with a sharp explorer. Only one cartridge of anaesthetic was allowed and no buccal infiltration analgesia used until the test for success had been made. A further category for failure was that when, despite this first test showing success, the patient showed signs of discomfort during dental procedure. The data collected for each local anaesthetic administration are listed in Table 1. These data were analysed using chi-squared and Poisson regression techniques to determine whether any of the recorded factors influenced the likelihood of obtaining successful analgesia.
Table 1: Information collected for each local anaesthetic administration
Factor Practitioner administering the anaesthetic Sex of patient Age of patient Quadrant Reason for local anaesthetic (procedure) Outcome of anaesthetic Possible values for factor 1-5 Male/female 6-93 years Lower left/lower right Conservation, periodontal therapy, endodontics, extraction Success/failure

Aims and Objectives

The aim of this study is to help provide some measure of expected failure rates and help dental practitioners in their self-appraisal of this crucial basic skill. It has to be emphasised that if a skill cannot be measured it cannot be managed. However, armed with some information regarding expected failure rates, general dental practitioners will be more able to audit their own results.

Methodology
One hundred consecutive IDB analgesia procedures for four dentists were recorded. In a subdivision of this study 200 consecutive IDBs for a fifth dentist were recorded. This dentist had the greatest experience of giving IDB analgesia of the dentists in this study. In this part of the study the dentist made a note if he anticipated that the procedure would fail. The reason for this was that it was felt that experienced dental practitioners could predict when failure was about to occur. The incidence of any facial nerve palsy was recorded. Anaesthetic technique A 27 gauge long needle was used. The anaesthetic in all cases was lignocaine 2%/adrenaline 1:80,000. Self-aspirating syringes were used in all cases. Although there is evidence to suggest that accidental intra-arterial injection can be avoided with traditional local anaesthetic cartridges8 the practice involved in the study had used the Astra self-aspirating system for many years. The classic IDB technique was used. This involves injecting into the
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Results
For up to 100 consecutive IDB analgesia procedures (200 for one dentist) the following information was recorded for each patient: date of birth, sex, quadrant anaesthetised, dental procedure performed. The number of patients (458) is fewer that the number of IDBs (580) because some patients returned on several visits during their treatment. The results are displayed in Tables 2, 3 and 4. Five hundred and eighty inferior alveolar nerve blocks were administered by the five participating practitioners during the course of the audit. The recipient patients varied in age from 6 to 93 years old, with a mean age of 38.4 years (standard deviation 16.8 years). There were slightly more female (298, 51.4%) than male patients in the sample. Half (292, 50.3%) of the patients received the local anaesthetic as part of conservation treatment. The next most common procedure requiring inferior alveolar nerve block was extraction (138, 23.6%). Overall, 533 (91.9%) of local anaesthetic administra-

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Table 2: Distribution of dental procedure type for the total sample

Procedure Conservative/restorative procedures Endodontic procedures Periodontal procedures Extractions Total Frequency (%) 292 (50.3) 85 (14.7) 66 (11.4) 137 (23.6) 580 (100.0)

than some may have expected. Interestingly dentist 5 had wrongly predicted IDB failure in the case that developed facial nerve palsy. It appears that the procedure was identified as differing from the usual on that patient at that time.

Discussion

In this audit of inferior alveolar nerve blocks, the only recorded factor that could be shown to affect the chance tions were deemed to be successful. The success rates of a successful local analgesic was the operator. This for each of the potential explanatory factors are shown reinforces the notion that successful analgesia is techin Table 3. The only factor that significantly affected the nique-sensitive. The implications of this are that training likelihood of success was the practitioner administering should continue through a dentists vocational training the local anaesthetic, and this was only borderline statis- year and beyond. A regular audit of success rates would tically significant at the 5% level (chi-squared 4 df=9.56, help practitioners to determine whether their technique p=0.048). In order to be certain that the other factors did was improving as they would expect or not. not affect the outcome, the data were re-analysed using The greater success rate of IDB by the most experienced dentist was not unexpected. However, it is accepted that Table 3: Success rates for inferior alveolar nerve blocks by potential this is a small study. There is also the explanatory factors possibility that the greater success of Factor Value of factor Administrations Successes (%) P-value more experienced dentists is proPractitioner 1 179 169 (94.4) 0.048 vided by other confounding vari2 109 105 (96.3) ables. It is said that dentists get to 3 97 84 (86.6) 4 88 80 (90.9) know their patients and this helps 5 107 95 (88.8) in, for example, providing successful Sex of patient Male 282 258 (91.5) 0.727 IDB analgesia for their patients. This Female 298 275 (92.3) may be true. An established practiQuadrant Left 297 277 (93.3) 0.216 tioner may have a large group of Right 283 256 (90.5) patients who place increased trust in Procedure Conservation 292 268 (91.8) 0.238 Periodontal 66 63 (95.5) their dentist, having built a relationEndodontics 85 74 (87.1) ship over a number of years. There Extraction 137 128 (93.4) is potential at least for some degree of placebo effect on success. Howthe technique of Poisson regression. This technique ever it is unlikely that this would extend to the patient investigated the effects of each of the factors in turn continuing with surgery or extractions if analgesia was while controlling for the differences in success that can not successful. be attributed to the different practitioners. The regression Perhaps patients get to know their dentist, the point analyses (results not shown) also did not detect any dif- being that if a dentist provides unsuccessful analgesia on ferences in success that could be attributed to any of the several occasions the patient is likely to seek treatment other recorded factors. elsewhere. This may lead to a certain amount of self-selecThe percentage failure rates for each dentist are tion with more established practitioners treating a group shown in Table 4 with additional note of the number of of patients on whom IDB is successful. If this were true years since qualification. then there would also be a group of patients who sought Dentist 5 felt that he could identify when failure was treatment with a new dentist. The least experienced about to occur immediately following the procedure. The results show that in eight out of 10 failures the prediction Table 4: Percentage failure rates for each dentist was accurate, unexpected failure occurring only in two out of a total 179 consecutive IDBs. In only one case did Number of % Failure the dentist predict a failure and the IDB actually achieve years since rate of IDB success. This raises the question that if failure is prequalification an analgesia dictable should dental procedures be postponed at Dentist 1 Less than 1 10.1% that point and alternative methods of pain control be Dentist 2 Less than 1 9.0% considered? Dentist 3 4.5 years 11.2% An incidental finding in the study was that facial Dentist 4 14.5 years (8.5 years PT) 3.7% nerve palsy occurred in two patients. The dentist was Dentist 5 14.5 years 5.6% different in these two cases. This gives the complication Total 580 IDB procedures 8.1% an incidence of 0.3% in this series. This is possibly higher
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dentists in this study were new to the practice and were treating a higher proportion of patients who were new to the practice. There is the possibility that some of these patients were from a different self-selected group, namely who had found IDB unsuccessful in the past. Meecham1 put forward the case for using a blunderbuss approach for patients who had experienced failed anaesthesia in the past. The rationale is that it is more difficult to gain patients trust if they have been hurt in the past. The blunderbuss approach is to use IDB and buccal infiltration from the onset with the possible addition of a second IDB higher up the mandibular ramus. Dentists in this study achieved successful IDB analgesia at the second attempt after failure had occurred. This may be because it is easier to move the needle painlessly in tissue and palpate the bony landmarks. Also a higher needle position was employed on all repeat injections. Factors identified by dentist 5 that helped predict an unsuccessful IDB were: Unable to locate anatomical landmarksespecially the pterygomandibular raphe. Unable to find a bony landmark with the needle. Unable to direct the needle satisfactorily due to tough tissue in the pterygomandibular space. Awkward tongue. Either excessively large or due to lifting posteriorly. Some patients seem unable to allow the tongue to rest passively. Difficult anatomy where posterior teeth have been lost and alveolar resorption has been excessive. Needle curved when withdrawn. This is usually a sign that the dentist has struggled to manipulate the needle within the tissues. It is interesting that some practitioners seem reticent to provide IDB analgesia using other techniques whenever they can. Although dentists cite infiltration analgesia as more comfortable than IDB analgesia, there is evidence to show that patients do not perceive any difference.11

Conclusion
Inferior alveolar nerve block analgesia (IDB) is an important feature of general dental practice. This paper gives an insight into the possible success rates to be encountered by general dental practitioners when they administer IDB analgesia. The only recorded factor that could be shown to affect the chance of a successful local analgesic was the operator. The incidence of facial nerve palsy may be more common than has previously been considered.

References
1. Meechan JG. How to overcome failed local anaesthesia. Br Dent J 1999;186:15-20. 2. Heasman PA, Beynon ADG. Clinical anatomy of regional analgesia: an approach to failure. Dent Update 1986;Nov/Dec:469-76. 3. Simon JF, Peltier B, Chambers D, Downer J. Dentists troubled by the administration of anaestheic injections: Long term stresses and effects. Quintessence Int 1994;25:641-6. 4. Evers H, editor. Handbook of Dental Local Anaesthesia. Copenhagen: Schultz Medical Information, 1981. 5. Rood J.P. Some anatomical and physiological causes of failure to achieve mandibular anaesthesia. Br J Oral Surg 1977:15:75-82. 6. Cowan A. Minimum dosage technique in the clinical comparison of representative modern local anaesthetic agents. J Dent Res 1964:43:1228-9. 7. Crean S, Powis A. Neurological complications of local anaesthetics in dentistry. Dent Update 1999;Oct:344-9. 8. Meechan JG, Czachur KJ, Blair GS, McCabe JF. The ability of traditional and self aspirating dental local anaesthetic cartridges to aspirate blood under simulated arterial conditions Br Dent J 1986;160:239-41. 9. Gow-Gates GAE. Mandibular conduction anesthesia: a new technique using extra-oral landmarks. Oral Surg 1973;36:321-8. 10. Akinosi JO. A new approach to the mandibular nerve block. Br J Oral Surg 1977;15:83-7. 11. Matthews R, Ball R, Goodley A, Lenton J, Riley C, Sanderson S, et al . The efficacy of local anaesthetics administered by general dental practitioners. Br Dent J 1997;182:175-8.

Acknowledgement: Miss G Taylor for help with illustration. Correspondence: DA Keetley, The Manor House, Bramcote, Nottingham NG9 3DR. E-mail: we04@dial.pipex.com

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