Arguably endodontists have to deal with the most difficult to numb pulps due to inflammation.  Most endodontists begin with two cartridges of anesthetic as well as infiltration for mandibular blocks.  Some patients require intrapulpal injections.

It is difficult to compare with medicine.  Al Reader's group uses electric pulp testers to evaluate efficacy.  This is a very harsh test.

Thank you, Paul, for your comment. Indeed, dentists do experience that IANB has the lowest success rate of all regional anesthetic techniques they administrate, specially when treating hot teeth, i.e, in dentistry.. But, this fact  is not an evidence that this block has the lowest success rate in medicine. And I still wonder who demonstrated that IANB is the "worst" block.

All the best.

Thierry.

Hi Thierry, I believe that if this statement comes from his books and papers, you could use them as references since he is a worldwide leader in the field.

Like dentists, physicians perform procedures not requiring general anesthesia in patients that may be having pain, anxiety, lowered pH of inflamed tissues, nerve altered resting potential, anesthetic resistant sodium channels, red hair, etc.

In addition, physicians use very similar anesthetic compositions and concentrations to those administered in dentistry.

As a result, it is my humble opinion that the main reason for their profound anesthesia success is that they take into account accessory innervation when getting numb their patients.

Wise words from Dr. Malamed, it would be nice to find their original reference(s) as you suggested

All the best,

Dan. 

Thierry, would you mind to point out the specific reference in which this opinion is found (if book, please include page(s) number(s))?

Please advise.

Thanks,

Dan.

Thank you, Dan, for your comment, and your request.

First of all, an explanation for my late replying : as general rule and by respect for my family, I try not to  let my  professional activity impinging on our personal life, so that I do not do anything dealing with dentistry on weekends or during holidays. That’s why I reply only today.

Here are two samples of Stanley Malamed’s statement : the first one in the most recent edition of his « Handbook of local anesthesia », page ; the other one, with a very slight difference in the formulation, in a conference he gave in Spain at the end of 2015.

My « problem » with this is not what is said ;

My  question  is : where does this assertion come from ?

* is it just an opinion, a personnal feeling, drawn from his huge experience, not only as a dentist, but as a dentist anesthesiologist : for example, considering my personnal cursus, I have absolutely no expertise in blocks other than oral blocks : I can say, like most of us, that by everyday experience : «  I strongly believe that mandibular blocks have the higest failure rate among all blocks performed in dentistry. » It is an interesting opinion, but nothing proves I am right.

 I have nothing against the fact that one gives an opinion, especially when it comes from somebody who masters anesthesiology with perfection.

*or, is it a fact, something that was demonstrated, either by himself, or by other authors : in that case, I would be very interested in having the references in the literature, because I was unable to find anything by myself.

May I add that I very respectfully sent emails to S. Malamed, in order to get some clarifications on these points : I got the automatic receipts for my emails, but no answer to my –probably- silly or embarrassing question.

So : has anybody references supporting S. Malamed statement ?

All the best.

Thierry

Hi Thierry,

Thanks for your response, Malamed's paragraph is indeed a powerful statement.

I tried myself to find another source/reference unsuccessfully.

My suggestion would be to use it as an expert opinion until proven otherwise.

An expert opinion comprises a level of evidence 5 in research.

Has anybody references supporting this statement?

All the best,

Dan.

Dear dr:Thierry Collier .

your question is a very interesting question and very astute observation ,and i would like to add my point of view here .

i gave inferior alveolar nerve blocks for many years( i am a maxillofacial surgeon)  and it was the only technique i was taught and did thousand of extractions with it,until i went to a conference in in 1980's in  Colorado USA to attend Dr. Malmed presentation and there Dr; Malmed mentioned that  ( IANB has the highest failure rate among all local anesthetic blocks in Medicine) the same words he uses today against the inferior alveolar nerve and he suggested  at that time the Gow gates technique . If i remember at that time he gave percentage of success of Gow Gates as some thing like 90%.i also remember that during my doctoral study  in the 70's i read a apaper published by Gow Gates(first time)i have  enclosed it here as  an attachemnt and historic reason ) i read it and was fascinated by it but because i was trained on inferior Alv  nerve block I  never tried it. However  once i went to Dr. Malmed lecture i changed my technique to Gow Gates .I should say here in defense of Dr Malmed at that time (1980's) he said if your Inferior alveolar block fails don't keep giving the same one switch to  Gow Gates,when i returned from  the conference i began to use Gow Gates. Also i remember at that  conference  Dr: Malmed he either quoted a  study he  Did or based on other data and  then he  came up with his conclusion in regards to the inferior Alveolar nerve  block failure

That topic of inferior alveolar N is very interesting i know two professors in the same university if professor A gives lecture(this years on anesthesia)  he insists that students uses the inferior alveolar block and the other professor(if it is his year to teach anesthesia) he  insists on never using the inferior alveolar bloc and using only the Gow Gates.

i have never talked to either  professor  why are they insistent on their technique and rejecting the other.???

finally i should  let you know that your question is a very  interesting and stimulating and has been sustained   by following Dr; Malmed who in my opinion is highly respected in his area all what you need is to find the data he told us in 1980's

i hope i have helped

sincerely Yours

Dr.K.A.Galil.Professor of Dentistry

DDS.,D.Oral & Maxillofacial Surgery,PH.D,FAGD.,FADI.,Cert.Periodontist(Royal College of dental surgeons )

,Developer of The patented first App in Oral Histology for i Pad,i Phone ,i Pod Touch

visit the web site

https://itunes.apple.com/us/app/dgohe+/id1015383607?mt=8

 and down load a free demo ,look at the bottom of the page .

see Dr.Galil listed as  #17 on 51 first researchers

http://www.uwo.ca/research/51_firsts/

https://www.uwo.ca/research/_img/about/Publications/51%20Firsts%20English.pdf

Yes, according to many researchers, the inferior alveolar block has the lowest success rate and I am 100% with what Dr. Galil said.

Thanks for Dr Galil’s and Dr Aoun's comments.

To Dr Galil : as English is not my native language, I'm not absolutely sure I completely understood what you wrote. In particular: at the conference you have attended, in the 1980s, did Dr Malamed actually provide a bibliographic source or a personal study he would have made, or other data ? Can you tell me this?

About  Georges Aoun’s remark:  of course, we all know that the success rate of the IANB is disappointing, explaining the numerous attempts for other alternative or additive methods (Gow-Gates, Akinosi, cervical plexus block, intraosseous). This is not the point I wanted to discuss. My main question was : what statistical study showed that the IANB is the anesthetic technique whose success rate is the lowest of all loco-regional anaesthesia techniques administrated in medicine (and not only in dentistry: in our limited area, the thing is amply proven)?

So far, the matter remains unfortunately  unresolved.

And let me reiterate that it is a great pity that Stanley Malamed, who participates in Researchgate, does not want to give us his point of view.

Thierry COLLIER

Hello Dr Thierry COLLIER:

first thank you for your reply. Your English is absolutely great i hope my french reaches half or one quarter of your English knowledge i will be very happy .(yes i do speak french but very little )

second  i am not here to defend Dr Malmed he certainly can defend him self!

Third .i understand your point, you want  what we call these days "Evidence Based Medicine " which we Canadians coined it first in the world  " from our university Mc Master university  by dr David Sackett. if you want that concerning the inferior alveolar nerve low rate of success then a study has to be made ,i did not till now see such a study

However i will address your question about the the conference i attended in the 1980's with Dr Malmed .

I remember from Dr Malmed conference in the 1980's and actually even recently  that he has experience  of forty years as a professor of anesthesia at University of Southern California and during these forty years when he was called upon to help in the dental school or University hospital  it was always the inferior alveolar nerve in injection which was a failure or causing the problem to the dentists/students /resident and etc  .Dr Malmed states that the inferior alveolar nerve has the lowest rate of success based on a survey he did by asking the dentists but did not publish the survey and  and i saw that survey in the lecture (and it said very clearly not published) and most of the dentist pointed(in that survey) to the inferior alveolar nerve injection as having   the lowest success rate compared to other teeth anesthetized

just some facts here

do you know that the inferior alveolar nerve injection has been the same since it was introduced by a medical doctor by the name of Dr Halsted  in 1885  and we are still using it till now !!.

so to answer your question directly do i have a statistical study or evidence based medicine  that the success rate of IAN injection is the lowest ? the answer from my readings is no I don't have ,  but may be some one else knows.

Best wishes

Sincerely Yours

Dr.K.A.Galil.Professor of Dentistry

DDS.,D.Oral & Maxillofacial Surgery,PH.D,FAGD.,FADI.,Cert.Periodontist(Royal College of dental surgeons )

,Developer of The patented first App in Oral Histology for i Pad,i Phone ,i Pod Touch

visit the web site

https://itunes.apple.com/us/app/dgohe+/id1015383607?mt=8

 and down load a free demo ,look at the bottom of the page .

see Dr.Galil listed as  #17 on 51 first researchers

http://www.uwo.ca/research/51_firsts/

https://www.uwo.ca/research/_img/about/Publications/51%20Firsts%20English.pdf

This discussion is totally futile. Its like arguing that the Hemlins Piper was the worst in catching rats & the person asking this question is the Mayor(AUTHOR in this context) who refused to give due credit to Pied Piper (IANB in this context)

HENCE I WOULD REQUEST THE MAYOR TO ASK QUESTIONS WHICH WILL DO SOME GOOD TO MEDICAL & DENTAL FRATERNITY.

THE ONLY MOTIVE ACHIEVED BY SUCH QUESTIONS (MISCONCEPTIONS) OF THE AUTHOR IS TO IMPROVE RG SCORE. ELSE THE AUTHOR WANT US TO BELIEVE THAT HE IS NOT AWARE OF THE EFFICACY OF THE BLOCK.

Even the dumbest of the final year student who has ever given IANB in a proper manner is well versed of its efficacy. SO BASICALLY THIS DISCUSSION IS FOR THOSE WHO ARE NOT CLEAR WITH THEIR BASICS OF GIVING LA & WANT TO IMPOSE THEIR FAILURE/ INEFFICIENCY OVER IANB BLOCK.

SO I WOULD REQUEST ALL TO END UP THIS DISCUSSION (MISLEADING CONCEPTIONS OR SHOULD I SAY MISCONCEPTION) & DISCUSS ANY TOPIC WHICH WILL THROW SOME LIGHT ON ANY UNTOUCHED TOPIC

LAST BUT NOT THE LEAST:

THE CHEETAH WHO BAGS FINAL POSITION IN THE RACE WITH OTHER CHEETAHS MIGHT BE LAST .....

BUT THAT WOULD BE OUR STUPIDITY TO DISCUSS "DOES THE CHEETAH IN FINAL POSITION KNOW HOW TO RUN?"

IANB might be LAST in success rate when compared to other blocks but definitely not the LEAST effective when treating mandibular teeth.

ELSE MAYOR SHOULD TREAT ALL MANDIBULAR TEETH STRICTLY UNDER GA ONLY AND NEVER ADMINISTER IANB

I thank Mr. Alok Dubey for his very ingenious metaphorical allusions to a medieval European legend ( even though there is much to discuss about the adequacy and comprehensibility of his curious parallels) and his very entertaining and subtle zoological analogies (although they sound a bit farfetched) : I do praise Mr. Dubey for his generous spirit of invention, which allows us to enjoy his devastating humor.

However, I doubt that these reflections are likely to enlighten the primary subject.

I would like to clarify -with serenity and courtesy, but without doublespeak- on both the substance and the form of Mr. Dubey’s intervention.

1-On the content itself:

I am afraid that Mr. Dubey did not read with sufficient attention the original question, nor, moreover, the various contributions, some of them, in particular those by Dr. Daniel Uzbelger Feldman, demonstrating a perfect analysis and understanding of my interrogations.

I need to stress, again, that I am not the author of the statement that “the IANB has the lowest success rate in medicine” (not only in dentistry): it is Prof. Stanley Malamed, who is, as far as I understand, a universally recognized specialist in Oral Anesthesia. Having said that, I tend to agree with Dr Malamed’s opinion; the only thing that still annoys me (a little) is the fact that he did not explain to us how he came to this conclusion, despite repeated requests (directly or via internet).

Precisely, my question was: How did Stanley Malamed come to this assertion?

The question was not: “Does the block of NAI have a reduced success rate?”, because there is a vast consensus on the subject, as shown in any up-to-date books dealing with dental anesthesia.

For example:

Alfred Reader, John Nusstein, Melissa Drum: Successful local anesthesia for restorative dentistry and Endodontics. Second edition. Hanover Park, IL: Quintessence Publishing Co Inc, 2017.

Mr. Dubey explains:

” THE AUTHOR WANT US TO BELIEVE THAT HE IS NOT AWARE OF THE EFFICACY OF THE BLOCK.” (sic)

I am perfectly aware of the efficacy of the IANB, particularly during surgeries (but the necessity of administrating a buccal nerve block might reinforce the global success rate of the IANB), and even more aware of its lack of efficacy in many cases: the authors of the book cited above, after reviewing not less than 21 articles, write, page 42:

“Table 2-1 shows the percentage of success rates in various mandibular teeth. It is important to realize that 100% of the subjects in these studies had profound lip numbness. [2–19,21–23] Success occurs most often in the molars and premolars and less often in the incisors.

IN CONCLUSION, anesthetic success varies from 51% in the first molar to 10% in the central incisor

even though patients have profound lip numbness.”

End of citation.

Anyone who treats endodontically symptomatic mandibular posterior teeth, and reads these articles knows that this question is pointless.

In chapter 2, dealing with mandibular anesthesia, no less than 19 pages (out of the 43 pages of the chapter) explain why and how IANB fails, and how to improve its success rate.

So that the conclusion drawn by Mr. Dubey seems a bit inadequate:

“Even the dumbest of the final year student who has ever given IANB in a proper manner is well versed of its efficacy. SO BASICALLY, THIS DISCUSSION IS FOR THOSE ARE NOT CLEAR WITH THEIR BASICS OF GIVING LA & WANT TO IMPOSE THEIR FAILURE/ INEFFICIENCY OVER IANB BLOCK” (re sic)

The barely subliminal message delivered by Mr. Dubey is that I am unable to administer IAN blocks (I probably compare –not favorably, I am afraid- with the “dumbest of the final year student”), solely because I dare ask a (semantic, not technical) question. He implies that he himself has a remarkable success rate in that exercise: no one doubts it and we all welcome his abilities.

At the end of his diatribe, Mr. Dubey writes:

“SO, I WOULD REQUEST ALL TO END UP THIS DISCUSSION (MISLEADING CONCEPTIONS OR SHOULD I SAY MISCONCEPTION) & DISCUSS ANY TOPIC WHICH WILL THROW SOME LIGHT ON ANY UNTOUCHED TOPIC”.

This final injunction proves to be highly comical when we read the vital and innovative questions that Mr. Dubey proposed, two months ago, at the sagacity of the scientific community (Mr. Dubey has a very personal concept of an “untouched topic”):

- “What is the amount (mg) of lignocaine in 1.8ml carpule of local anesthesia?”

- “What is the maximum recommended dose of 2% lignocaine with vasoconstrictor in a child?”

I do not intend to be unnecessarily cruel, but I must recall that Mr. Dubey is, officially, « Associate Professor in the Department of Pedodontics and Preventive Dentistry, College of Dentistry, Jazan University, Jazan, Kingdom of Saudi Arabia”, and tells us, in his Researchgate profile, that his skills include « anesthesia, pediatric anesthesia, toxicity », amongst numerous capabilities.

So that, after responding his first question, and discovering the second one, I thought it was not incongruous to wonder why an Associate Professor in Pedodontics is led to make such simplistic demands, whereas, by his function itself, this topic is precisely what he is supposed to know, and a fortiori, to teach. Therefore, considering the utterly absurd aspect of the situation, I suggested that the author of such questions probably needed to artificially increase his "visibility" on Researchgate.

I can certainly understand that Mr. Dubey is not absolutely delighted that I made such a hypothesis. For now, and awaiting further explanations, I reiterate my view and I sign.

This rather epic episode explains Mr. Dubey's wrath towards me; but it gives us no satisfactory explanation on the reasons why he asks such basic questions, considering his prominent situation in his university.

May I also stress that his intervention did not allow any sort of progress for my initial questioning.

2-On the form:

Mr. Dubey probably believes that stressing all his text by using capital letters provides it with some additional profoundness. For example:

“LAST BUT NOT THE LEAST:

THE CHEETAH WHO BAGS FINAL POSITION IN THE RACE WITH OTHER CHEETAHS MIGHT BE LAST .....

BUT THAT WOULD BE OUR STUPIDITY TO DISCUSS "DOES THE CHEETAH IN FINAL POSITION KNOW HOW TO RUN?"

I am reasonably confident that -nearly – all readers in Researchgate globally understand what they are reading, and do not need any typographic alteration to detect the main points in a text.

As a rule, the greatest statements are rarely shouted. It is considered disrespectful and rude to others using all caps. People "in the know", those who are convinced of the accuracy of their speech do not use all caps. The so-called “Netiquette” very wisely suggests refraining from using all capitals ...Moreover, ultimately, underlining a whole text stresses nothing: it is of no use or interest.

Finally, as proof that I am not a bad bugger, and in order to conclude in a pleasant positive way, I will give Mr. Dubey a personal opinion (this is not a tip, I would not dare!): to treat your pediatric patients, rather than using an IANB, try to administer an intraosseous anesthesia, using a Quicksleeper : immediate onset, profound analgesia, and lack of lip, tongue, cheek anesthesia, perfectly well tolerated by children, possibility of treating in more than one quadrant, minimal amount of anesthetic solution... And it works with a remarkable success rate for MIH. Who could reasonably ask for anything more? You will thank me, for sure…

If you would like further details, I will be more than happy to provide you with all the necessary information.

Dr Thierry COLLIER.

Thanks for your personal opinion on Quicksleeper...........

&..... yes a well knit fable

.