Articaine ID Blocks and the ‘CIA Technique’ for Local Anaesthetic – PDP143

Jaz’s Introduction:
I’m actually, I wouldn’t say afraid. I’m not afraid of doing ID blocks. I’m just do them way less because I’m afraid of some of the POTENTIAL COMPLICATIONS that you see in papers and in opinion articles about the potential risk of paraesthesia and other complications from ID blocks, and therefore I’ve been a bit put off. So what I did many years ago is I started to do more and more articaine infiltrations, buccally, and to be fair like I told Wayne, Dr. Wayne Williams, the prosthodontist who’s a fantastic straight talking guests.

I love straight talking guests. Right? You’re going to love him too. And I shared with him that, look, I only do about one ID block a month. A) Because I’m getting so much success with my buccal articaine. But B) Because I’m being overly cautious, I’m really trying to prevent it.

Because I think this scare mongering has worked on me. I am a little bit worried about the risk and the more ID blocks you do, the more you increase your risk or so I thought, because there’s so much we talk about in this episode in terms of the power of a buccal, articaine, but also, knowing when to respect and knowing when that might not be serving your patient the best, and why he should be perhaps doing some more ID blocks.

And in fact, Wayne even says that he’s a huge advocate of articaine for ID block. So we’re going to cover a lot of controversial topics and as you heard already, Wayne is no stranger to controversy and I love that so much. One thing I really respect about Wayne is that he helped to develop the CIA, the Crestal Intraosseous Approach. I had to really, it’s a bit of a tongue twist. I had to really think about that. So the Crestal Intraosseous Approach and no, it does not involve drilling into the bone. It does not involve buying a quick sleeper or something like that, involves actually what he teaches us, is really cool about the anatomy and how there are these mystery canals in the bone.

And we can actually utilize this to make our infiltrations with articaine far more success. And so because he started to develop and use this technique a lot, he actually would lecture many years ago and say that you don’t need to do ID blocks anymore. So he went through that phase himself, but now he’s gone a full 180 and he really believes in effective anesthesia through inferior alveolar nerve block. So I think you’ll really gain a lot from this episode, which is covering so much of bread and butter dentistry.

Protrusive Dental Pearl
The Protrusive Dental Pearl is related to a couple of videos I posted recently on YouTube and on the app. So this could gain a lot of attraction. So one video is called Robin Hood Dentistry. And so what this is about is stealing from the rich and giving to the poor.

And what I mean by that is if you have a lower molar, for example, that’s completely beat up, right? It has exposed dentin, it has got cracks and it needs restoring. It will really benefit from restoring, but there’s no space because the upper plunger cusps sits right inside there. So what I talk about in this video, and I really encourage you to watch this video, rather than just go by this pile here, is the use of Robinhood Dentistry.

Careful and well considered enameloplasty of this pointy sharp cusp to make it into a rounded cusp. It’s much better stress distribution and sometimes it’ll remove a bit of height, but you don’t want to flatten the cusp, right? You want to follow the cuspal contours so that you can then have space to restore the lower molar.

And you can apply the Robinhood philosophy to anywhere in the mouth. And the reason I love it so much is because you show patients the photo and you say to them, you have a very aggressive opposing tooth. We have a very sharp corner of this opposing tooth, and we need to do some Robinhood Dentistry.

We need steal from the rich and give to the poor. We are taking away from this arch and we’re giving to the other arch. So communication wise, patients really get it and it’s good to tell them before you do it. Otherwise it looks a bit sloppy. It doesn’t look very professional if you’re having to adjust the opposing arch after you’ve carried out some restorative dentistry, right?

There is a second video that’ve also added. It’s called No More High Restorations, right? We replace those beautiful composites under rubber dam. We take the rubber dam off, the patient bites together, and we’re drilling away our beautiful anatomy. Well, if you want to watch the free version on YouTube, just read the show notes and click on or just type in YouTube, no more High Restorations Protrusive.

You’ll find my 20-minute video, and if you’re on Protrusive Premium, there’s a 30 minute plus video of showing the adjustments after as well. When there are some adjustments needed, how to keep them minimal, and how to be efficient and very accurate in your conformative dentistry.

Main Episode:
Hope you enjoy this main episode with Dr. Wayne Williams, and I’ll catch you in the outro.

[Wayne]
Because some of the stuff will be controversial. A hundred percent. I can tell you now it will be controversial and I’m up for that as well. No, I’m totally up for that.

[Jaz]
Amazing, and I love that. So, without further ado, let’s actually welcome you on, so I’m actually might keep that bit in. Actually, Dr. Wayne Williams, welcome to the Protrusive Dental Podcast. How are you, my friend?

[Wayne]
Yeah. Very well. Thanks, Jaz. And, as I’ve said to you before, really delighted to be with you and part of the movement that you’ve started and that’s been going for so long now and doing so well. So thank you again for the invitation. Great to be here.

[Jaz]
Well, thank you for your kindness and thank you for emailing me that day and tell me about what you do, but also you are talking about skiing and how it could have worked out. You were in Morzine. The week before we were for that ski-PD trip. So hopefully next one we’ll make sure that you’re an educator for that because, I looked at your CV.

I was so impressed. Wayne, you have a amazing CV. So for those listening, haven’t heard of you, please let us know what is the day in, day out kind of work you do. What are the things that drive you, I mean, from speaking to you before we hit record, you’re so fascinated. You got very, we’ve made multifaceted, but please tell us about what drives you.

[Wayne]
That’s very kind. The profession’s been great to me. Jaz, I’ve been very, very fortunate. Grew up in South Africa, had my undergrad and post-grad education at universities, two different universities in South Africa. Left those shores towards the beginning of 2000. Arrived, went straight into Harley Street.

Did two or three years in the city and a bit of Holly Street, great experience and then decided the commuting wasn’t for me. Thank you very much. And I’ve set myself up in the countryside, in the Royal County of Berkshire and have a lovely practice. We’ve been here for almost 20 years. My wife’s a general dentist.

I’m a specialist prosthodontist on the register here and very much still involved. I love what I do. I love doing all the prosthodontic components that we do implants, big full rehab cases. Lots and lots of specialist perio work in our surgery and just loving life. I was very fortunate in that early in my career.

In fact while I was in my postgraduate program in South Africa, my Prostho program, four year full-time program, I was offered the opportunity to do some work in local anesthesia. And became very involved at that point with a company called Milestone Incorporated in the United States. The manufacturers of the wand, which you’ll hear a lot about in the next few minutes, I guess.

And that took me around the world and I was able to, with a team of other researchers and people around the globe, but mostly in the states, develop techniques and study anatomy and physiology and understand what local anesthetics all about? So that’s taken me to, I think I’m at 31 countries now around the world that I’ve taught. Lectured attended academic institutions and conferences, and so very fortunate, but glad to be in Great Britain.

[Jaz]
Well, it’s obviously you have such a vast knowledge and experience and also your specialist prosthodontist at then day. It’s amazing. Like I said, multi-faceted man. So I’ve got so many questions.

I’m looking at them now. And then while you’ve been talking about the wand and stuff and I realized, gosh, I want to ask you about intraosseous and that kind of stuff. There’s so much we can go in. So, yeah, this could be a very wild. So thanks for introducing yourself. Let’s start with the first one, right?

Let’s start with the first one, which is, how far can you go with buccal infiltrations with articaine for lower molars? Is this the end of ID block? So your opinion, also what you practice and what you preach. Because for me, I give about one ID block a month if that, and I do, I treat a lot of low molars. What about you?

[Wayne]
Yep. So really interesting one, Jaz. So in 2000, 2001, I introduced a big, big international meeting in Israel, a technique called the CIA, wait for it. The Crestal Intraosseous Approach. And I introduced that because we found a skull and it happened to be in Israel at the Hadassa University that I only then realized what the bone in the maxilla and the mandible really really looks like.

And to answer your question, if you’ve got thick buccal plates, and we know that the buccal plates along the mandible are of our thickest bone in the body because it’s our protective sort of zone to try and get local anesthetic to infiltrate through dense cortical bone. Not so easy. What a lot of people don’t fully appreciate either is, in my experience over these years, is we are dealing with a drug that’s been given in the buccal sulcus into what’s called a supra periosteal environment.

So the buccal infiltration, the correct terminology is a supraperiosteal infiltration, an SPI. And you hoping that, that drug will go through the bone. And the reason people are using articaine for that purpose is it’s 4% concentrated, meaning it’s got double the dose not because again, you ask people, what’s the difference between 4% articaine and 2% lidocaine?

And people go 2%. Well, it’s not, it’s a hundred percent, it’s a hundred percent more, 4% is a hundred percent more than 2%. And basically we are using articaine for a reason because we want that strong concentration. We kind of wish it to go through that buccal cortical plate. Not so much, sadly, to say.

What actually happens is if you’re dealing with a young patient and it’s highly porous, it’ll go through and you’ll have a lot more success. And it’s a great technique and it’s one you should be using. So, I now use regularly. It depends on what procedure you’re doing. If you’re dealing with a hot tooth, less successful.

Yes, if you’re dealing with a small DO or MO restoration, highly successful. Sometimes those restorations you could have done without the anesthetic anyway, so it’s kind of a placebo sometimes we don’t always realize it. What is guaranteed is the next time you get a chance, go online. If you come to one of my lectures, come to one of my presentations, you’ll see slides of many, many skulls on the crest of the mandible is a massive open area with holes in it and drop your anesthetic in there.

It goes straight down into the medullary part of the bone and gets to the nerves of the teeth. So rather than coming in buccally, I’m going in Crestal Intraosseous Approach. So not going down periodontal ligaments. Let’s get that one out the way straightaway. There is no such thing. It’s a complete misnomer. There is no such thing as a periodontal ligament injection. Get rid of that.

[Jaz]
So intraligamentary, as they call it, right?

[Wayne]
It doesn’t exist, doesn’t exist. It’s complete misnomer. There’s a lot of literature to back that statement.

[Jaz]
What about that device, Wayne? You know that, I forgot the name of it. There’s Projected Press, what’s it called?

[Wayne]
There’s 12 of those at least. Yeah, there’s 12 of them. Okay. There’s Ligmaject, there’s Peri-Press, there’s sigmaject, there’s, and so we can carry on. There are 12 at least of those. Quick Sleeper, however, is different. A quick sleeper wants to draw through the cortical bone, which is what I’ve just told you.

We need to get through the cortical plate. So to answer your original question, buccal infiltration is fantastic for single tooth procedures, not for multiple tooth procedures. So this type of intraosseous anesthetic works for limited times in my experience in research, 30 minutes. So you go in, you go out, you’re out. As soon as I start treating more than two or three teeth in an arch, I’m giving an ID block.

[Jaz]
But you said intraosseous a second note. Do you mean sub supraperiosteal you mean?

[Wayne]
No, so I’m still going. I never, I hardly ever give in the buccal sulcus unless I’m doing a very minor procedure. I’ll always put the needle intracrestal between the two teeth distal to the one that I’m actually an anesthetizing because the nerve comes from the posterior.

So I use a technique called the CIA Crestal Intraosseous Approach for all my single tooth anesthesia in the mandible, in the posterior segments, and the anterior segments for that matter. Because the anterior segment is often more difficult to anesthetize because the cortical plate here is even thicker in some of these areas.

So I think a lot of the time we do get success. In fact, the majority of buccal infiltration, supraperiosteal, albeit, but with limited timeframes to the success of that. And also if you’re dealing with hot teeth or teeth that require acute treatment, you’re less likely to be successful, but also I think one has to just be selective with which teeth you’re treating.

[Jaz]
Anyone with a large masseters, big square jaw. I’m going to be going for the ID block. And also for, yeah, multiple restorations. It has been my experience as well. And of course the hot pulp, all those things you mentioned. But if we talk about the crestal injection technique that you said, I forgot it already.

[Wayne]
CIA.

[Jaz]
CIA.

[Wayne]
Crestal Intraosseous Approach.

[Jaz]
Fine. So, you’re putting the needle in from the top and are you going into the attached gingiva or the muco gingival junction or the alveolar lining?

[Wayne]
Imagine the papilla.

[Jaz]
Yes.

[Wayne]
Into the so-called col area, COL.

[Jaz]
Yes, yes, yes.

[Wayne]
If you go back to periodontal-

[Jaz]
So you want to just see it blanche?

[Wayne]
It’ll start to blanche buccal and lingual. The spread of that anesthetic if it’s got a vaso. And that’s the other thing, you must use a vasoconstrictor. Yeah, for all those techniques, if you’re using a non-vaso constrictor, very limited five minutes duration on average. The problem with this technique is that because it’s intraosseous, it’s almost equivalent to intravenous or intra arterial, ie. it’s going straight into our main bloodstream.

The biggest blood vessel in the body is the medullary bone, and it goes straight in there. And because we have arteriovenous shunts in the head and neck area, it goes to the brain without getting infiltrated through our lungs, which is where a lot of the pH modification of local anesthetic takes place.

So this is one of the reasons people get vasovagal. This is one of the reasons people get edgy about it, and you have to just be aware that patients can have palpitations.

[Jaz]
Yes.

[Wayne]
When you’re delivering these drugs, intraosseously, whichever technique you’re using, quick sleeper, CIA technique. Tell the patient before the time, expect perhaps a couple of little alterations to the heartbeat can get a little quicker, but it’ll ease usually within about 30 seconds.

The key issue here is to lower the pressure at which you deliver that drug. And the speed at which you deliver the drug. So Poiseuille’s equation, pressure, time, and volume. The slower you give the injection, less volume over a longer period of time, gives you lower pressure. Higher speed, increased volume, increased pressure.

So without using the wand, good luck. Seriously. So just to put this in perspective and I need to get this out perhaps a little early on. I have no interest in the wand or Milestone Scientific haven’t for many, many years, although I was a clinical director early on in that company, I haven’t touched a handheld syringe of any type since November, 1998.

And we do sinus lifts, full mouth perio, full mouth reconstructions, major implants, major grafting in our clinic. We only use the wand and have since November, 1998.

[Jaz]
Wow.

[Wayne]
So there are no handheld syringes. No clinician in my surgery in our practice is allowed to use anything other than the wand.

So we’ve looked at all the other devices, quick sleepers, Peri-Press, Ligmaject, you name them all. The safety device from Septodont. Good product at least that allows some form of safety in dealing with needles, but the old, antiquated, handheld syringe, as most people know it, 1853, that device was invented, used by Charles Pravaz, a French veterinary surgeon.

Veterinary surgeon, but everybody says they have a modern dental practice. I find that rather fascinating. We use a computer to give out drugs, but the point going back to the CIA is any intraosseous technique you’re using, you need to be controlling and you’ll know when you press on your syringe and you are in those areas.

You have to press pretty hard. You’re going to develop carpal tunnel syndrome at some point. You’re going to have sore fingers and sore wrists at the end of that day. But imagine the pressure, and myself and Mark Hochman in the States have been the only publishers. We’ve measured all those pressures within the body for all these techniques.

Wow. We generate some serious pressures and no wonder patients have postoperative pain when you’re using these intraosseous techniques. If you sub periostal, so in the palate and in the buccal sulcus, if you do go subperiosteal in the buccal sulcus and you manage to get that blanching and the pushing away of the periosteum from the cortical bone, that builds up a lot of pressure, Jaz, and creates some pain.

[Jaz]
Look, I agree with you and it’s something that I do, I must admit, and I might change our practice after speaking with you, but, you know, I’ve seen the downsides of this, Wayne, I’ve seen two ladies who came back with bruising down their neck before.

Okay, so I don’t know if you’ve seen that probably because you are using the ones who probably have maybe pre-wand days, but you know, thousands of patients. But it’s still upsetting to me. So I did change my practice after that, really making sure that the pressure element is respected. But usually what I do is, I do give it in the suraperiosteal, as you said, but then also into the attached gingiva and also mesial and distal in those right cases that benefit.

[Wayne]
Fantastic.

[Jaz]
So, yeah. Is there any way that, so we can keep it safe?

[Wayne]
Drop the subperiosteal part because all that’s doing is it is giving you soft tissue anesthesia, so for your cord packing or raising a flap or anything of that nature. But the other bit will be the bit getting to the nerve of the tooth.

Always remember where the nerve enters the tooth. That’s where you’ve got to get the needle. And so my whole start to all of this, 20 plus, 25 years ago was understanding flow dynamics in the human body. So I started studying what happens to that drop of liquid that comes out of the end of a needle, irrespective of what device you’re using.

I started by studying the flow dynamics of those liquids, and that gave me the key to everything else that I’ve ever developed and known since. And if you think about that, when every time you’re giving an injection and you think about the direction that your needle is going in and where that liquid is going to end up.

So what a lot of people, again, don’t really think about with this technique we are just discussing is you’re blowing that liquid out the end of that needle with your finger pressure and it’s hitting that cortical plate, bouncing off it, and going straight back into the soft tissue. It’s not actually going through the cortical plate to where you want it to go, where the nerve is inside of the apex of the tooth.

So the only way to get it to the apex of the tooth is to go through holes in the bone. And that’s why the Quick sleeper was a good development, or the Stabident, which a lot of people know in this country. But people are drilling through cortical plates to get a needle tip through. Good luck to find that spot, however, if we look at the anatomy carefully and we should all go back and look at anatomy.

If you want to think about good local anesthesia, then look at the crestal aspect of the mandible. There are holes waiting to be put through and that’s where we should be putting the needle.

[Jaz]
And how do you know when you’re through? Because you want to be your depth of needle.

[Wayne]
Again, if you are using the wand, you hand holding it like a pen. You have manual dexterity, you have manual tactile feedback with the handheld syringe. We lose all of that, Jaz. That’s why I’m not a proponent of the handheld syringe. It’s cheap and easy, but it’s not the right way that we should be delivering local anesthesia. It’s not possible for everybody to invest in more expensive technology.

I get that. But the truth is to answer your questions, it only comes from tactile, perceptive ability to know when you’re in these right places. And with the CIA technique in particular, I was only able to evolve and develop that technique through the tactile feedback. I know exactly, literally the needle drops through. You can actually feel it. Pulsate it.

[Jaz]
And is this something that’s possible with a 30 gauge a needle, or does it have to be the something like the wand?

[Wayne]
Always 3-0 gauge. Well, the wand uses 3-0 gauge, we use 3-0 gauge half inch needles. We only use two needles in the wand, 3-0 gauge half inch, 27, 1 1/4 for blocks. But I want to go back to two things, If I may. Do you mind me jumping back?

[Jaz]
Please, please. I’m loving it. This is golden.

[Wayne]
The one that you spoke about, the bruising. The bruising’s really interesting. So when Hochman and I published and measured all these pressures in the human body, it is phenomenal for dental techniques.

What was actually happening in your patient that had the bruising? You were rupturing venules and arterioles. You were actually rupturing those soft tissue vessels because you had such high pressure at the end of that needle with that fluid building up pressure and it causes rupture of those vessels.

That bleeding then from those vessels, goes into the soft tissue and gives you the bruising and the only way you can avoid that is by reducing pressure, and the only way you can reduce pressure is by giving slow delivery. So the one whole mechanism is a drop at a time. So a drop comes out. If you imagine this being the bone, the drop hits that bone, the drop gets absorbed before the next drop gets there.

That drops already into the bone. Then the next drop arrives. So drop for drop drip feed, almost like an infusion pump in a hospital. Rarely. And the second point I wanted to make was why, if I may ask, cause I think a lot of our colleagues will be asking this possibly, why would you choose to be doing buccal infiltrations?

Are you somehow trying to avoid inferior alveolar blocks? And if. I’d be very interested cause I know the answers. I think I’ve heard them many times. Why are you trying to avoid an inferior alveolar block?

[Jaz]
Brilliant.

[Wayne]
That takes us into a whole new area.

[Jaz]
Yeah, yeah. Oh, let’s go to New York. Let’s go there. But just point on the point of bruising is really fascinating. Because this is the first time it’s happened to me, but it happened on two ladies the same week. It was strange. It really blew my mind. And I think maybe it’s because I’m very slow. I’m usually very slow injecting.

But I look back and I think, okay, here’s what I do. I go very slow in tissues. So they don’t feel anything. Once they’ve got the soft tissue anesthesia, then I think I went too fast. Cause okay, they’re numb now. So I knew, I learned from that, that, okay, keep it slow even if they’re numb already, because it’s really good for them.

So I think that’s what happened. And then, so why am I doing so many buccal infiltrations, is to avoid ID blocks. So why are we, the question is really, why are we avoiding ID blocks? I’ll be honest with you. I’ve read some of Tara Renton stuff and it scares the bejesus out of me, right? So, okay.

[Wayne]
Okay.

[Jaz]
So this is, well this is what it is. So for those of you who aren’t familiar with it, then you know, ID blocks may cause injury and Paraesthesia, et cetera, et cetera.

[Wayne]
You’ll have to give Tara my mobile number. She’ll probably have it already. And great respect to Tara. She’s done a lot of work in this field, and I respect her work and I get it, but if I’m honest, I don’t agree with almost everything she writes about this.

I don’t agree with a lot of it. I probably only use non-ID block because of the type of work I do. Vast amounts of treatment and choosing not to use a CIA for a lot of cases. Probably 85% of the time I’m using an ID block still. There was a short time when I made the discoveries around the CIA that I went back and said, ah, want to now, you know, discovered this technique and now I’m going to use that a lot and put the ID block in.

And in fact, in my lectures, many people in this country will have heard me say, oh, get rid of the ID block, blah, blah. I’m totally, totally back on ID blocks and have been for the last two decades, at least the last 15 years. So one, because I know they’re safe and every single ID block I give almost, almost without exception, is using articaine. So we need to get rid of that misconception.

[Jaz]
That was, yeah, that was one of the questions as you saw. So let’s hit that on the head. Okay. So we are medical legally. Will that be defensible? Is one of the questions I’ll ask you.

[Wayne]
Well, now we’re into quite tricky territories, so I’m going to be careful on this one. But in our clinic for the last two decades, and this is not a, this is anecdotal reporting, however, it’s also based on speaking to people in 31 other countries. Now let’s just go and start in Germany.

Let’s start in Germany, 80,000 dentists, UK, 30,000 dentists. Roughly, 80% of all injections given in Germany are given using articaine. All injections. All techniques. Only 20% are not usually where they can’t use adrenaline or choose not to use adrenaline.

[Jaz]
Got it.

[Wayne]
That’s another subject. Their percentage. So you’ve got 80,000 people using 80% of the time articaine, 4% articaine. Why do don’t they report a single percentage remotely higher than we do for paraesthesia in the mandible with an ID block.

[Jaz]
Exactly.

[Wayne]
And my hypothesis on that is because articaines got nothing to do with it. What it has got to do with, and there are recently published papers on this without proof, there is no clear proof.

If there was Jaz, hang on one second. If we knew for a fact, if Tara and her companies and people that she works with, if they knew that this was seriously dangerous, do you think we’d still be allowed to give ID blocks with articaine?

[Jaz]
Yeah, we wouldn’t. No.

[Wayne]
I don’t think we would. So I don’t think there’s sufficient evidence to say that is. However, there is sufficient evidence for people to be scared of that, but it’s because they don’t understand what the problems are with Paraesthesia. For one minute, think about what the primary cause of paraesthesia is. Traumatic.

[Jaz]
It’s got to be trauma. Trauma from the needle. Right?

[Wayne]
A long needle.

[Jaz]
Not the agent. Yeah.

[Wayne]
And I’m sorry, also to point out that predominantly the voice of anti articaine, anti ID block use comes from maxilla facial oral surgeon departments of which Tara may or may not be part of. I’m not sure, but the truth is, are they not perhaps looking for alternative reasons for the cause of that trauma?

Or the reason for the cause of the paraesthesia? And how can we ever prove whether a needle has hit that nerve or not? And how can we ever prove whether it is with lidocaine, articaine, mepivacaine anything else, what actually causes that? And that’s part of the problem here. So I’m not suggesting for a minute that people should just at a whim, start using articiane for all their ID blocks.

They need to checklist for themselves. In my clinic, after a long, long time, I’m 58 years old. And I work every single day, four and a half days a week now at predominantly six days a week for a long time, doing lots and lots and lots of ID blocks, only using articaine. And you know, anecdotally, I can tell you many stories of maxilla facial oral surgeon, one in particular who worked with me and alongside me for a long period of time.

And when he first joined us, he was part of the group who went, I’m not touching articaine near an ID block and within a few months he only uses articaine. And two decades later he’s still using articaine for all these ID blocks. And the reason we use articaine is because it’s so much more effective because it’s doubled the concentration of Lignocaine.

So the single most difficult injection to get a predictable outcome for, you’re telling me we want to be using the lowest concentration drug. I say no, the least predictable of all the techniques we use, we need to use the highest concentration of drug in a safe environment. And you have to be able to aspirate because that’s now the next domain we go into is, oh yes, but I have this reaction and people are that, and again, we’re going into blood vessels, but we are not aspirating.

And if you’re aspirating with a handheld syringe, you’re getting false negative aspirations if you’re doing it. Because most people tell me they’re not. If we treat ourselves, every single case we do with a wand, irrespective of where we inject automatic aspiration. Automatic aspiration, which means we can keep the needle still and it doesn’t go back and forth in and out of the blood vessel.

So we are getting two aspiration results. Does it mean we’ll never have a problem? Of course it doesn’t, but it reduces that risk tremendously. But to answer the point regarding articaine and ID blocks, I’m yet to be convinced. And I want to see clear research data before I’ll stop using articaine for ID blocks.

[Jaz]
That has been really eye-opening. I think that’s good to hear. Refreshing. So thank you for sharing that with the Protruserati. With Hitting Bone, I asked this on another episode as well. One of my strategies when I do give an ID block, which I feel in my head is keeping safe is I was taught to hit bone at dental school, but then I heard from this surgeon called Radislow guy, he says, don’t hit bone because that deforms this tip of the needle and that’s what could be causing the trauma. And so therefore, I stopped hitting bone. What should I do?

[Wayne]
Okay, so Jaz. One of the advantages of working with a microscope and using high magnification, as you’ll probably know as well, is honestly a lot of my injections, I examine the needle straight after infiltration or for ID blocks, and I’m yet to be convinced or see bending.

And I do touch bone. I think hitting bone is probably a strong term. Forcing needles into bone is quite strong. But the reason I had to study this at the time and still do look at it carefully is because I used the Crestal Intraosseous Approach so much. There’s a distinct chance that my little 30 gauge, half inch long needle can hit a harder piece of the bone and deform even break.

Dare I say, I’ve never seen one. I’ve read them in the literature and legal cases, but the truth is there is a potential for deformation. I take that point, but I think you have to hit it. Remember, these are a medically grade devices that are being constructed. If they were that weak and we’re curling around every time we touch something, I’m not sure they’d be released into the human body.

But I’m not advocating that we press things hard against bone. I’m certainly not advocating, hitting things. But again, if you, and maybe again the wand comes to four because we just have that much more tactile sensation to be able to feel when we are hitting things or touching things. Cause we are holding it like a pen and all other devices are held as if we are holding, I don’t know, boxing glove or, so I don’t know what it is, but you guys do this stuff.

But the truth is, again, I’m yet to see that, but I do share your concern if that needle does curl up and I’ve seen pictures of those, it’ll ripple the tissue as it comes back out as well.

[Jaz]
Yes.

[Wayne]
And the drug won’t go to where you want it to go, but are you going to ask at some point, sorry, was there anything more on that point? Because I was about to ask you, do you know what the failure rate of an ID block is across the world?

[Jaz]
Oh, wow. This is a really interesting one, Wayne. Okay. So my immediate guess would be 50%. But this is an educated guess because when I was in Vietnam, as a fourth-year dental student, I was with a very experienced dentist.

He was in his sixties at that stage. And so, the protocol, we were in this Vietnamese rural area with these orphans. We were giving them dental care. And the protocol was that we give the kids two ID blocks because he said we know that half of all ID blocks fail, so let’s give these kids two ID blocks. Okay, how kind are we? And then we’ll do their treatment. So that’s where that number is stuck in. But I’m sure you have a more research answer.

[Wayne]
There’s a slightly more researched answer. So again, a publication because I like to go back to publications wherever I possibly can. And in some of these areas there aren’t, the articaine one is a difficult one, but the failure rate has to be a very high potential for 25%.

And the reason it’s 25% at least, and that’s a least figure, I think you’re probably right, it’s probably closer to 50% possibly. There’s no publication on that number, but in a paper by Hochman and others in the states. Some years ago, they took x-rays by putting ID block in particular needles. So length, 27 gauge one and a quarter inch needles through bits of meat, and then they x-rayed what was happening to those needles.

Bearing in mind that dental needles are beveled only on one side, whereas medical needles sometimes are beveled on both sides. So when you have an arrow, sorry, correction to myself, medical and dental needles are beveled on one side, but when you have an arrow, it has two sharp points like this, so when it goes through soft tissue, it goes through straight by cutting through on both sides, whereas our needle is only beveled on one side and orthodontists in the audience will know.

If you push a beveled instrument of that nature through soft tissue, it will always deviate to the site towards the bevel. So they studied this and what that means is that when you’re holding a handheld syringe and you aiming for the lingula, because you always have to be above, or at least in line with the lingula to get anesthesia for the inferior alveolar nerve.

If you are using a straight instrument and that arrow’s going straight, the needle’s going straight, but then curves down as you’re doing it. And there’s lots of x-rays that we were then able to show with this curved needle. And it dips below the lingula. That’s a failed anesthetic. So when people aim low, or when the needle curves low, so even if you’re aiming Gow Gates style really high, which is what I advocate, go really high, go too high rather than too low, but then aspirate because you’re getting close to the pterygoid venous plexus lots of things to be scared of.

So you go up high, but if your needle then bends, you’re still going to fail because 25% of the time it can either go up 25% down, left, or right. It can go four ways that needle, depending on where your bevel is. So with a wand, what we then discovered was if you rotate that needle back and forth, you change the position of the bevel and it goes dead straight every time exactly like an arrow.

So you’re creating bevel there, bevel there, bevel there by rotating just 180 degrees. And that’s the reason I can honestly hand on heart, tell you I cannot remember when last I gave a second ID block or when I had a complete failed ID block. Decades ago. Literally decades ago.

[Jaz]

Amazing. And so the question I have now, I mean, to visualize the needle bending in that way is fascinating. I think.

[Wayne] Take a piece of meat. Put it through, and then take some x-rays, don’t, I don’t know how you’re going to get around the x-ray radiation part of that, but yeah. And stand outside the room and all the rest. Or read up Mark Hochman, H-O-C-H-M-A-N Publication, probably early two thousands. Mark Hochman Bevel translation in needles.

[Jaz] Which is why sometimes, I see my patient’s notes and there’s a note saying, difficult to, aim higher because it could be that. Now my next question is, you mentioned about the technique with a one in terms of rotating, would that work with a handheld traditional anesthetic? You can’t do that, right?

[Wayne]
I’ve challenged people to do that because there’s always somebody in an audience somewhere. And that’s global by the way they go, I don’t hurt patients. You know, I do thousands of inject. I don’t need the one, I don’t hurt people. All my patients tell me they love me. I’m painless. I’m the best in the world there. And they also tell me I don’t have failed ID blocks and et cetera, et cetera. And I say, well, that’s great. You know, tell me how you do it.

Cause I can learn something. But. Then you always get someone also that I don’t need the one because I can do that with my handheld syringe and I say, well, show me. And it’s just physically give it a try for yourself. If you can let me know. Cause I’d love to learn that technique and, you know, put myself wrong.

But, honestly, it’s physically impossible. And whether that’s a safety injection or whether it’s a handheld syringe, whichever, especially the 1853 Charles Pravaz one, that’s impossible.

Jaz’s Outro:
Brilliant. Next question, I guess in the theme of anesthesia failing, I was at a lecture by my friend, Lincoln Harris, and he mentioned interesting things about redhead, which I knew already. Red people with red heads, they’re more difficult to numb, but also, large heads because large heads have large bones. So should we fear the large headed redhead? Is that true or false, that myth, or is that real? And any strategies to help the large headed redhead if it’s true.

Well, there we have it. Guys, thank you so much for listening all the way to the end. And because you made it through the end, if your Protrusive Premium, answer a few questions based on this very engaging, very real world episode, and you can gain some CPD, how good is that? So if you’re not already on the app, head to protrusive.app on your browser, sign up and get CPD and watch exclusive content.

We of course, left you on a cliffhanger. So there is a part two coming where we finally find out is it a myth or is it real, that red-headed large headed people are more difficult to numb. And also find out which are the three types of anesthetic that Dr. Williams keeps in his practice. Okay, so I’ll give you a clue actually, out of Mepivacaine i.e. Scandonest, Lidocaine, and Citanest, we already know use articaine.

Okay? Out of those three so Citanest, Lidocaine, and Mepivacaine, one of them he thinks is absolutely useless and we shouldn’t be using it. So you’ll find out which one that is next time as well. And if you’ll listen to this, and it happens to be before the 21st of March, then this is your final chance to get access to OBAB for two whole years.

And get a fully mentored case worth 550 pounds. Thereafter, you’ll have to pay for mentored case support, right? So in the discussions, yeah, we’ll support you all day, all night, but if you want us to spend time to go through fully your case and give you structured feedback, then we will do that. But that’s a paid feature.

If you one of one fully mentored case, then that is available if you enroll before the 21st of March. So hope to see you there and we’ll catch you in part two of this episode.