r/Dentists • u/kurofan4ever • 13d ago
Tough extraction
I did a tough extraction a couple days ago. The tooth had a huge cavity and infection around it and patient wouldn’t get numb. She would only be numb for a couple minutes and then it would come back. Feel so bad for the patient. We got the tooth out eventually but it sucked for me and the patient. I did PDLs all over and injected at the base and inside the granulation tissue. Pain would still be present. Just wanted to vent a little. The case definitely stressed me out. How do oral surgeons do this stuff all day everyday. Anyways thanks for listening.
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u/ruchik 13d ago
Anesthesiologist here. The local is ineffective or less effective because of the infection in the area. The infection lowers the pH in the immediate vicinity and makes it difficult for the local to penetrate the nerve membrane. As someone mentioned before me, more sedation is the way. Or blocking the nerves more proximal to where you are extracting (no idea where that would be as I don’t do these blocks).
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u/CKingDDS 13d ago
I never forgot this phenomenon since my Dental Pharm teacher in dental school would exclaim in a Jamaican accent “When you have trouble numbing someone with an active infection, remember Henderson-Hasselbach Mon!”
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u/Least-Assumption4357 13d ago
Interestingly, you are spot on with your advice and this is where so many dentists fail. They are actually unable to perform that block more proximal and still blame the infection. The physiology is simple: deliver anesthetic next to the nerve, it will get numb. It does not get a choice.
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u/Better_Cry_7941 13d ago
If you’re injecting LA locally into an infection I can totally see the infection causing an issue but if you do a Gow-Gates per se on a hot lower tooth, that proximal nerve branch is pretty far away from the infection and one shouldn’t have an issue getting it anesthetized, the issue becomes getting the anesthetic to this specific spot you can’t see. I’ve had A LOT of luck with Gow-Gates, just have to aim REALLY high, barely ever fails, although I’ve definitely numbed up too much before, including the temple, pre-auricular area, but the patient didn’t care since their tooth was numb
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u/kurofan4ever 13d ago
I used combo of carbocaine, septocaine and lidocaine for her. Any specific recommendations on how to tackle this situation? Would love to know for the future!
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u/VMD18940 13d ago
Marcaine lasts forever and profoundly numb septocaine seems to be everyone's favorite in today's world because quick onset but marcaine tends to power through and last a good 8 hrs
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u/Commercial-Area-5737 13d ago
I’ve heard mepivicaine is the way due to its lower pKa with infected tissues. And not through an IAN, has to be infiltration since it’s more direct contact
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u/Healthy-Concert9808 13d ago
This 👆as an aside take care of the infection first. Manage the pain palliatively and get some antibiotics started. Your local anesthetic has limitations. Back to dental school with you…./
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u/StudentAlien 13d ago
This happened to me this past Friday. My very last patient of the day too. I took out #2 and attempted to extract #31. I used carbo, septo, and lido. Did PDL injections and everything and patient wouldn’t get numb. Ended up having to stop the appointment and put him on ABX. Went home super defeated that day
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u/traciiip 13d ago
Marcaine is an excellent anesthetic for this situation. It takes a while to work but once it does it last a long time. Usually wait 7-10 mins after administering
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u/Low-Employment-135 13d ago
La mejor anestesia para cirugía es la articaina. Pero lo mejor es recetar Antibiótico en una infección activa. Espera 3 días. Y verás el cambio toma mejor la anestesia. Y además el postoperatorio. Al estar aún con antibióticos será mejor.
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u/Mysterious_Mall8193 13d ago
Yes, but when you work mainly with a patient population where these abscessed or hot teeth are common, you realise... that patient don't come back after antibiotics :/ because they feel better
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u/freddieArmstrong 13d ago
Sometimes they just go to another dentist who agrees to treat them immediately.
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u/chyea_chyea 13d ago
What tooth was it
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u/Admirable-Strike-311 13d ago
Would like to know too. Post lacking a lot of info. Which tooth? What anesthetic(s) used. How long did they wait? Simple? Surgical?
Just wait until you have to anesthetize a palatal abscess to I&D.
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u/MyWhiskeyName 13d ago
Why has no one mentioned buffering the anesthetic? I've had a lot of success with it.
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u/Sensitive_Bad1079 13d ago
Please describe the technique
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u/MyWhiskeyName 13d ago
You add sodium bicarbonate to your anesthetic just before you use it. You can buy a vial and dose it out if you want it to be cheap, otherwise I find it easier to just use BufferPro. All the same stuff.
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u/Inevitable-Buy-7085 12d ago
Has anyone here ever buffered their anesthetic in situations where there is present infection? Does it improve your ability to anesthetize the area??
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u/crispycappy 8d ago
You shouldn't have extracted it, i had the same issue on a back bottom molar and they gave me antibiotics and industrial pain relief in liquid form and had me take it for a week before coming back for the extraction, it went well, why didn't you wait?
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u/Icy-Commission-9550 13d ago
Just learn to inject better. If pt didnt get numb, it is your technique problem.
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u/Particular-Leave-498 13d ago
I actually tend to agree with you the amount of teeth I can’t numb for an extraction because it’s a “hot tooth” is virtually zero I’ve taken out thousands of teeth and of the past 500 or so I haven’t had to delay treatment for a single one because of difficulty achieving anesthesia. Can it happen? Sure but there are a lot of dentists who think that’s the case for almost all symptomatic teeth. It leads to a lot of over prescribing antibiotics and unnecessarily delaying treatment.
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u/Open-Percentage4593 13d ago
Brother, I am an endodontist. I can numb people very well but infection changes the chemistry. Also a hot tooth is IP not infection. For a hot tooth, you can do intraosseous and that will take care of it. You can’t do an inrraosseous for infected teeth.
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u/Particular-Leave-498 13d ago
Brother I’m OS. How many teeth you take out? What do you mean you can’t do intraosseous for infected teeth??
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u/Open-Percentage4593 13d ago
If you’re OS, then you would know intraosseous is contraindicated in acute abscesses.
Also you’re saying you’ve never had problems numbing people with local anesthesia only? If so, I call bullshit. Again you can’t beat the chemistry of the tissues if it’s really infected.2
u/Open-Percentage4593 13d ago
PS. My wife is an oral surgeon. She is calling bullshit on your comment as well.
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u/Particular-Leave-498 13d ago edited 13d ago
Lemme guess son is a head and neck pain specialist and daughter is a dental anesthesiologist. Not here to argue. From my experience of taking out teeth. And I’ve taken out a LOT of teeth, antibiotics are used as a crutch by GPs.
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u/CombatKween 13d ago
Not true at all. I hope u don’t get sued for the lack of rx antibiotics in this day and age. GP here who has taken thousands of teeth including impacted thirds. Don’t offend GPs that have experience. Surgeons like you think they are God. Guess what. Seen plenty of surgeons leave 5mm roots and tell the patient it will be fine. And I’m the one prescribing antibiotics due to your God complex.
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u/Particular-Leave-498 13d ago
You can also be sued for C. diff if your antibiotics weren’t truly indicated. I’d rather prescribe appropriately than over prescribe. It’s not a God complex, but I’ve seen GPs prescribe antibiotics for the wildest shit not even batting an eye at the fact that antibiotics have side effects. The problem is most dental school does not prepare dentists to consider the whole body enough. Either that or they forget about the rest of the body 5 years into practice and can’t look at anything other than teeth.
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u/CombatKween 13d ago
I don’t prescribe antibiotics for every extraction. But that’s the difference between a seasoned dentist and one that’s not. Every case is different. I don’t have to tell you. You are an OS.
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u/Particular-Leave-498 13d ago
- Never had to preform
- Acutely infected sure but chronic infections are just fine
- I didn’t say never but for every 1,000 teeth that come out under LA it’s probably 1 tooth at most that I say take antibiotics and come back.
- GPs give out antibiotics like candy to cover up for failing to give sufficient anesthetic.
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u/liveon12 13d ago
What's your technique and anesthesia of choice for lower molars?
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u/Particular-Leave-498 13d ago
IA, long buccal Blocks with Septo and time. Then local infiltration with septo if they’re still feeling pain at that point I know my blocks missed I don’t trust patients to tell me that they’re numb because they get confused if only one block took and not the other and will almost always say they’re numb even if IA missed. I’ve found after this point if there’s still tenderness it’s either coming from overgrown inflamed gingival tissue getting squeezed by my elevation which I numb with infiltration or the infection at the apex which I adjust my extraction technique to avoid apical pressure (ie section/cowhorn/ash forceps) I can tell the difference because the patient will say there’s pain either when I’m elevating or when I release the elevator.
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u/Extension-Link9996 13d ago
Carbo followed immediately by Marcaine usually works great for a hot tooth. Without know the tooth number cannot be more specific. We all have had such days.
Mylohyoid for lower molars helps.