Some notes on vertiprep

From the Oxford Handbook of Clinical dentistry:

"Lidocaine/adrenaline Most commonly used preparation (2% lidocaine 1:80 000 adrenaline), gives effective pulpal analgesia for 1.5h and altered soft-tissue sensation for up to 3h. Extremely safe; maximum dose (adult) 500mg (10 × 2.2mL cartridges) (4.4mg/kg lidocaine with 44mg per cartridge). Also available in ampoules 1% + 2% lidocaine plain or with 1:200 000 adrenaline. There are theoretical criticisms that the maximum dose is too high but these have not been borne out in practice, nor has the demonstrated effect of a change in serum potassium levels after lidocaine/adrenaline injection in the mouth.

Prilocaine/octapressin Similar but slightly less duration and effect compared to lidocaine/adrenaline. May cause methaemoglobinaemia in excess. Maximum safe dose (adult) 600mg (8 × 2.2mL cartridges). In reality, there are few hard indications for the use of prilocaine over lidocaine.

Mepivacaine Short-acting LA advocated for restorative work but has not really caught on. Maximum safe dose 400mg.

Bupivacaine Long-acting LA (6h plain, 8h with adrenaline); useful as a post-op analgesic. Maximum safe dose 2mg/kg. Only available in ampoules. Levobupivacaine is a similar drug.

Articaine At least as effective as lidocaine; said to diffuse through bone better. No hard evidence of superiority, however not recommended for IDB due to cases of permanent altered sensation after its use."

"Mental nerve block The mental nerve emerges from the mental foramen lying apical to and between the first and second mandibular premolars. LA injected in this region will diffuse in through the mental foramen and provide limited analgesia of premolars and canine, and to a lesser degree, incisors on that side. It will provide effective soft-tissue analgesia. Place the lip on tension and insert the needle parallel to the long axis of the premolars angling towards bone, and deposit the LA. Do not attempt to inject into the mental foramen as this may traumatize the nerve. LA can be encouraged in by massage."

Posterior superior alveolar block A rarely indicated technique. Needle is inserted distal to the upper second molar and advanced inwards, backwards, and upwards close to bone for ~2cm. LA is deposited high above the tuberosity after aspirating to avoid the pterygoid plexus.

Infiltrations The aim is to deposit LA supraperiosteally in as close proximity as possible to the apex of the tooth to be anaesthetized. The LA will diffuse through periosteum and bone to bathe the nerves entering the apex. Reflect the lip or cheek to place mucosa on tension and insert the needle along the long axis of the tooth aiming towards bone. At approximate apex of tooth, withdraw slightly and deposit LA slowly. For palatal infiltrations, achieve buccal analgesia first and infiltrate interdental papillae; then penetrate palatal mucosa and deposit small amount of LA under force.

Injection into an infected area should not be done anyway as this risks spreading the infection

"Thick nerve trunks require more time for penetration of solution and more volume of LA. In nerve trunks autonomic functions are blocked first, then sensitivity to temperature, followed by pain, touch, pressure, and motor function. Concentration of analgesic  rapidly around the nerve at first and provides soft tissue analgesia; however, this is reached substantially before the levels needed for pulpal analgesia, which takes several minutes and will wear off first (usually within an hour of a standard lidocaine/adrenaline LA). Disinfection of mucosa prior to LA is not required in reality; however, sterile disposable needles are absolutely mandatory due to risks of cross-infection."