As I write this, I can already imagine some of you rolling your eyes for what I'm sharing here. I get it. For many of us, it is easy to get into a routine where not only do we not calculate our anesthetic, but we don't necessarily even slow down to think about how much or when we have given it. And I get it as well, that by in large most of our patients are old enough and large enough and procedures small enough that we can get away with not calculating how much local anesthetic we have administered. I want to challenge you a little today. Before you scroll on and skip over this please think about this for a second.
I have a lifetime goal. I aim to eliminate local anesthetic toxicity. I have state board members and association members telling me in private that they see local anesthetic toxicity with almost every reviewed case with a negative outcome especially with our pediatric patients. We are all taught safe local anesthetic administration in school and many more times in CE. This isn't a lack of knowledge. This means some of us are willing to negatively compromise patients and choose to be lazy and not do math. Kids are getting hurt because of math. How many peds patients getting hurt or worse yet dying is a sufficient number for us to say no more? Me personally I love my kids. Nothing else in the world that I care more about. I say one is one too many. And I don't feel that me whining about it is the solution. This is why we have put together the most advanced local anesthetic tracker that is easy to use and can be used on any device, computer, platform whatever. We even added a feature to easily copy all the info straight to your progress notes. And its FREE. We want no excuses. We want to eliminate local anesthetic toxicity.
You may still say, "Travis, I really don't give much local so this doesn't really pertain to me." I understand where you're coming from. But might I ask one thing? Wouldn't you prefer to know exactly when and how much local anesthetic (or anything for that matter) was administered in the case of an emergent event? I'll admit, that I used to be proud of how I would keep all of the administered cartridges and then count them up at the end of a case and record the number. Until my eyes were opened to the reality that if any of my cases were to be reviewed or if an emergency were to occur, there would be no way to definitively prove that the local anesthetic doses were not excessive even though a great deal of time had passed from initial doses to follow-up doses. The only solution was to time stamp each dose.
As sedation or anesthesia providers, our relationship with local anesthetic isn't optional—it's fundamental. This is my challenge to you for those who are not already doing this:
1. Precision Is the Standard: Document Doses as They Are Given
We must stop retroactively estimating local anesthetic. It's not enough to chart the total number of cartridges. That's a unit of packaging—not of pharmacology. The only responsible approach is to record doses in real time, calculate mg per injection, and track total dosage by weight—especially in pediatric and small adult patients. Furthermore, I know this is review, but please don't forget that even when giving different kinds of local anesthetic, their pharmacological effects are additive. We HAVE to consider the total milligrams of all locals administered. This is not optional. This is not "extra."
2. Moderate Sedation Demands Mastery of Local Anesthetic Techniques
True sedation is not a solution for poor local anesthetics. In fact, poor local anesthetic techniques make sedation more difficult. This means we must go beyond dental school basics:
- Learn the Mylohyoid block for those elusive lower first molars.
- Use Intraosseous injections for precise, profound anesthesia.
- Master the Inferior Alveolar block. If you want what works in my hands, message me and I'm happy to share all I have.
- Use PDL injections with intention—not as a last resort. I had a fantastic pediatric dentist teach me the beauty of using PDL injections for all invasive pediatric procedures. I prefer the Septodont Paroject as kids don't see it as a syringe as it is disguised from a normal syringe and isn't the ginormous calk gun PDL guns we had in dental school. Who wouldn't be nervous with those things coming at you??
- If need be, explore other options such as the Wand, Woodpecker or the Dentapen by Juvaplus. (I personally have not used any of these so I welcome any feedback regarding them)
The sedation doesn't replace good local. It demands it.
Bottom Line
If we're not calculating doses per mg, we're gambling.
If we're relying on sedation to "make up for" poor local anesthesia, we're subpar.
All of us administer sedation or general anesthesia, but this is all very applicable for our non-sedated patients as well. I'd love it if you did me a favor and helped me with my lifetime goal. If you haven't already, go to xchart.com/local and try out our free local anesthetic tracker. We are hoping that by putting this in the hands of every provider, maybe we can prevent negative outcomes. Honestly, if we help one kid from being harmed, all the effort is worth it to me. If you already use our local anesthetic tracker, tell a fellow colleague. I would greatly appreciate it.
- Travis V. Coulter, DDS
Clinical Director, Xchart.com