A dental visit without Novocaine or Epinephrine?

lidocaine local anesthetic with epinephrine used at the dentist

Lidocaine with Epinephrine is the most common formulation in the U.S.

Since starting this blog in October 2012, readers have posted hundreds of comments on all aspects of dentistry. While the comments vary significantly, there is one subject area that is consistently popular. And it also happens to be the most dreaded part of a dental visit: the numbing shot!

This is not surprising, given that over 1 million local anesthetic injections are administered in dental offices per year in the United States alone. And did I mention how everyone hates the shot? People love to Google things they hate!

This post covers two areas that readers on this blog have commented about as well as questions that I receive on an almost daily basis in my practice in Orange, CT.

Epinephrine in Local Anesthetic

Patients are always curious about epinephrine (a.k.a. adrenaline) used in local anesthetic. First off, there is no such thing as an epinephrine allergy, a myth I thoroughly debunked in Dental MythBuster #10 – I’m allergic to epinephrine.

photo of epinephrine capsule used for injectionStill don’t believe me? Dr. Stanley Malamed, considered the world’s foremost expert in local anesthesia in dentistry, writes “allergy to epinephrine cannot occur in a living person” in the textbook he authored.

Can you get an injection at the dentist that does not contain epinephrine? Of course! Nearly all dentists should carry at least one type of local anesthetic without epinephrine. The most common is either 3% mepivacaine (brand name is carbocaine) or 4% prilocaine (brand name is Citanest Plain). Keep in mind that if you do receive local without epinephrine, the numbing feeling will not last as long and will be less profound.

If your dentist does not have that type of anesthetic available, you may want to consider switching offices.

Occasionally, you may receive an injection at the dentist and your heart races. This occurs when some of the epinephrine from the local anesthetic enters the bloodstream. It may feel a bit unsettling, but for most people, this is temporary and completely harmless. But this does not mean you are allergic to ephinephrine! See this page for more on that dental myth.

No Novocaine While Drilling?

First off, dentists no longer use novocaine, something I wrote about here. Interestingly, prior to the invention of novocaine, cocaine was actually used as a local anesthetic. It was quite effective, but there were some undesirable side effects as you can probably imagine.

photo of tooth cavity that needs lidocaine for fillings

These cavities are too big to be filled without any local anesthetic.

Many have commented on this blog asking if they can have dental work done without having local anesthetic administered. The answer is yes. Except in certain circumstances, the local anesthesia is for the comfort of the patient and is not required for the procedure. However, doing dentistry on a patient who is experiencing pain is not good for anyone involved!

In certain cases, I will however recommend that we attempt without any local anesthesia. These are circumstances when the cavity is very small and restricted to the outermost layer of the teeth. In these instances, little to no sensation is transmitted to the nerve of the tooth. Patients don’t feel anything except a little vibrations. They then leave happy because they didn’t receive a shot and therefore will not be numb for the next three hours.

However, if the prospect of potentially feeling a tiny bit of pain during the procedure scares you, do not ask your dentist to skip the local anesthetic.

What should you do?

For all the readers who have posted comments on these two subjects, keep in mind these two points:

  • Epinephrine is found in most formulations of dental local anesthetics, but you can always get local anesthetic without it.
  • It is possible to have dentistry done on you without local anesthetic. However, you should ask your dentist if the area to be worked on is small. If not, you will feel it!

Comments

  1. I need to have a previously root canaled tooth extracted (#31), and I am wondering if it would be tolerable to do it without being numb? If not, am I correct in thinking that receiving an injection without epinephrine may make the pain tolerable, but decrease the amount of time being numb? If so, could I get away with an injection that would only cause me to be numb for an hour or less? I know I am in the minority, but I would much rather experience some discomfort than be numb for hours.

    • Tanya,
      I have, on occasion, removed teeth on individuals without any local anesthetic. This was done at their request. I only consented to it because these were extractions that I knew would take 10 seconds or less. An extraction of #31 could be easy or could be very difficult and time consuming. It’s hard to tell without an x-ray.
      In general, epinephrine will make the local anesthetic last longer, and also produce a more profound numbing feeling. Your best bet is to ask your dentist to give you local without epinephrine. Hopefully you will be numb enough to tolerate the procedure.

      • Otis Sito says:

        I had all 4 of my (non-impacted) wisdom teeth extracted using the aforementioned Carbocaine 3% Plain.

        I was a bit concerned that I wouldn’t be numb enough, and, as such, I did discuss this at great length with my dentist, and he assured me the Carbocaine would be enough for these extractions. He was absolutely right!

        The Carbocaine’s effect was perfectly profound…I didn’t feel a thing with the teeth came out. I also felt that because he has The Wand it also made a difference.

        The palate shot that everyone hates was actually quite tolerable – and I hate pain! The lower “blocks” that can be quite uncomfortable were also surprisingly comfortable, and some of the “infiltration” shots were not noticeable at all.

        Of note, these were “simple” extractions as opposed to surgical ones.

      • I had an unpleasant experience with local anesthesia recently. I have unfortunately had a lot of work done to my teeth previously so I was/am no stranger to shots in the gums, numbing, puling, drilling, etc. The last time I had been to the dentist was 3 years prior. When I had gone then I had 14 fillings and 2 extractions done in 4 days. Everything went smoothly and the pain was normal for the work done to my mouth. Everything healed fine,etc.

        Then back in June I had an emergency tooth extraction done at a new dentist office. I chose this office based on when they could accept me, as it was same day and I needed to have my tooth removed due to pain I was experiencing.

        After I was given the shots of anesthesia I began shaking uncontrollably. Like my legs were bouncing off of the chair and my teeth were chattering. I felt like I was going to be sick. I had never felt that way before when given shot of anesthesia. They called my fiance to the back to hold my legs, as they would not quit shaking. The doctor said that I was fine, just probably nervous. I do have anxiety, but since I have had so much work done prior I was not nervous about the procedure. I felt very dizzy and a little confused. They proceeded with the extraction. As they were working in my mouth I began to feel extremely anxious due to the physical response my body was experiencing.

        I wound up not going into work that day because of the way I was feeling, which lasted about 3-4 hours after the procedure was completed.

        On a follow-up visit I spoke with the dental assistant about my experience. She said that it was likely just the response my body had to the epinephrine. I was surprised to learn that it was in the shot they had given me. Due to my anxiety I refrain from consuming any kind of stimulant like caffeine or certain medications, etc. Because I tend to have an unpleasant reaction to them. I have been without stimulants of this nature for 11 years.

        I did a bit of research and learned that not all of these shots have epinephrine in them, so I asked the doctor if I could have some without epinephrine in the future. He told me that it was nothing to be afraid of and that my body naturally makes it, etc. Essentially he told me it would be fine, and I shouldn’t worry.

        I have a root canal scheduled that I have been rescheduling for the past few months, mostly because I haven’t been able to take time from work, but mostly because I don’t want to have the same reaction as before. The doctor has made me feel like I wouldn’t be able to have shots without epinephrine at that office.

        Should I just switch offices?

        • Holly,

          This is not the first time I have heard a story like this.

          I would probably bet that you’ve received local with epinephrine in the past. Generally speaking, local with epi is almost always used, unless there is a specific reason to use an alternative.

          What was likely different in your last visit was that, due to chance or poor technique (or both), some of the epinephrine inadvertently went into your bloodstream, resulting is systemic effects. It sounds like this nuance wasn’t managed as smoothly as you would have liked.

          I use local without epi all the time. All offices should have it. When patients specifically request it, I am quick to inform them that it does not last as long and some patients can end up feeling some pain during the procedure.

          If you don’t want local with epi – and are well informed of the limitations of that local – you should communicate that to the office. If they still don’t want to do it, then I would look for another office.

    • Janet Irick says:

      Allergic to lidocaine, with anaphylaxis reaction. Allergist is not making any suggestions as to what other options are available. What could be some options in this case? Came up with general anesthesia, no anesthesia. Accupuncture. Clove oil……any other ideas. Not sure if I can handle no anesthesia. Fillings needed where previous fillings were.

  2. I just returned from the dental office to have a nonimpacted wisdom tooth extracted. The anesthesia was great I felt nothing and it was out in 5 minutes. However, as I was leaving I got light headed and fell, then it severely hit me and I collapsed. I sat in the office for 3 hours fighting off the nausea, lightheaded, dizziness, rapid heart beat, and feeling of fainting again. They said it was side effects of the epinephrine and I bottomed out. What ever that means. I drank a Redbull ( that’s all they had with sugar) and ate a pnut butter and jelly sandwich. Is this normal to last this long and to collapse? After I got home I checked my sugar and it was 240. Obviously from a combination of Redbull, jelly, and white bread

    • Laura,
      I wasn’t there to observe you but it sounds more like vasovagal syncope than “side effects of the epinephrine”. The wikipedia article on syncope is here: https://en.wikipedia.org/wiki/Vasovagal_response
      But are you diabetic? It could also be stress and hypoglycemia. But unlikely to be the epinephrine. At least, that is based on your description and having seen many patients experience syncope and/or hypoglycemic episodes with nearly identical symptoms.

  3. I have hyperthyroidism and can not have epinephrine. I have a 2 severly decayed and broken bottom teeth. One wisdom and the other is a 2nd molar i believe. Anyways i suffer extreme pain and antibiotics have no affect anymore. They have decided to pull them with just 3% no epi and wade awake. Scared to death they wont get them out in time before it wears off or even worse i wont be numb enouph at all. How long does this medicine work? And is this a really bad idea?

    • Carrie,
      I was not there to evaluate you but I can offer my observations.
      Having removed thousands of teeth, the teeth that are the most difficult to numb completely for an extraction are lower molars. And that is using epinephrine.
      A patient who cannot tolerate epinephrine is going to experience a less profound numbing sensation and for a shorter time period.
      An anxious/scared patient is difficult to numb as well.
      Putting all this together, I would say there is a chance the procedure will not go as smoothly as you would like. You may want to consider some type of sedation.

  4. Dear Doctor,
    Yesterday I had 6 teeth extracted using novocaine with no epinephrine. I felt every extraction. It was extremely painful, even though my dentist kept giving me repeat injections. She even admitted that it was in fact not even working. I have had the no-epi type before in the past and never had a problem. By the way, I am having several teeth extracted and will be getting partial dentures. I have 7 more extractions ahead of me. The reasons for the loss of my teeth are bone loss, root decay, and receding gums. I am 67. Why do you think that the local didn’t work. Could my dentist of yesterday be using a different formulation than what my dentist in the past used?
    My question to you is, will the local WITH epi be more effective for me for the future extractions? I do get heart palpitations from the epi, but as long as I know it is not harmful to me, I’m willing to go for it. I have no heart problems and no high blood pressure (other than white coat syndrome). What are my chances of having no pain with the extractions if I go for the local with epi? Also, maybe I could ask the doctor to prescribe lorazepam that I could take on the day to help calm me down. Maybe that would help the local take effect better if I am calmer. I am facing three more extractions next week, and then four more after that before they place my temporary partials. I cannot face the prospect of feeling every extraction again. Please advise

    • Virginia,
      I’m sorry to hear you had a bad experience.
      In general, local without epi is simply less effective than local with epi. If you are also nervous, then that can make you more susceptible to feeling pain as well.
      I think the major question is why you are getting local without epi. In my office, I inject without epi under two broad scenarios: First, the patient doesn’t want it. Or, secondly, there is a SIGNIFICANT medical reason to skip the epi. So, whose idea was it to skip the epi?
      Lorazepam would likely help – but you should check with the prescriber first before taking it

      • Doctor,
        Thank you very much for your speedy reply. To answer your question, I was the one who requested no epi. I did this because I have had palpitations with epi in the past. So my regular dentist, whom I used to see before I moved, always used no epi on me from the time I told him about the palpitations. As I said, when I had the no epi in the past, I never had any problem, even with extractions. That’s why I was so stunned when it didn’t work this time around.
        So today I had my post-op check up. I got a good report, my sockets are doing great. I had the opportunity to ask the doctor a lot of questions. I told her I want epi when I come in for my next round of extractions. She said that is fine. They will take my blood pressure to make sure that it is not elevated and they will go ahead with epi and see how I react as far as palpitations. I also asked her to prescribe a tranquilizer for me, so she wrote a prescription for xanax. I am to take one pill the night before and one pill an hour before the appointment. I am hoping that my next appointment will go significantly better than my last one. I feel confident that it will. By the way, I was extremely nervous last time, so as you say, I am sure that contributed to the fact that I felt the pain. The doctor did say today that the local with no epi kept wearing off. So the local with epi will last much longer. I have to put my trust in that.

    • Allya moore says:

      If i have any caffeine before dental procedures with the nonepi pain anaesthesia i will NOT get numb. I found that out the hard way while sitting in a dental chair!

  5. Hello,
    I have a dentist appointment Monday morning and I’m so scare the last time I was there I almost faint, I talked to the dentist and he told me that he can do the local anesthesia without the epi. to remind her on Monday; however I’m allergic to almost everything so my question is since she is going to use a different anesthesia there is any chance that I could be allergic to this new one? also there are doing 3 fillings how long will this new anesthesia will last. Thank you so much.

    • Vanessa,
      You indicated you were very scared and almost fainted. Fainting, or near fainting while at the dentist does not mean you are allergic to a substance the dentist is using. Allergies don’t normally present this way (fainting with no other symptoms). Your dentist can use a different type of local anesthetic. However, if you are still nervous, a different local anesthetic will not change our nervousness. And, in general, local anesthetics that do not contain epinephrine do not last as long and the numbing feeling is less profound.

    • Vanessa,
      Same exact thing happened to me…dentist injected anesthetics, left the room, and I just about passed out in the chair. I am highly sensitive to anything with caffeine – so assuming the epi did this to me. I mentioned it to the dentist when she returned, and basically she brushed it off saying I probably didn’t have lunch…or something to that affect. I know my body and my reactions…was clearly the epi. Mentioned this episode to a friend who is a hygienist and she suggest I ask for anesthetic without epi. Dentist was certainly fine with that – and all has been ok.

  6. The last time I visited the dentist I developed a severe rash on my body accompanied by intense itching, lasting for several days until I started using Benadryl. I am afraid that I have developed an allergy to the Atacaine injections they administered. It turns out that it is also a male desensitizer spray! I am afraid to get another injection from the dentist now as the reaction made me completely miserable and ill. What should I do? I have to go back to the dentist tomorrow for more work.

    • Gail,
      Your comment is confusing. Atacaine – are you referring to articaine? Which is the male desensitizer spray? Articaine is a local anesthetic only and is rarely used outside of dentistry.
      Might you be allergic to latex?
      There are a ton of variables here and jumping to the conclusion that you are allergic to what was injected is a huge leap.

      • Reading through comments and I can answer this one. I don’t know about articaine, but benzocaine is used in condoms and lubricants for men who want to attenuate sexual feeling and supposedly can thus last longer.

  7. Hi,
    I commented a few weeks ago about having a terrible experience at the dentist where I felt every extraction. I had been given local anesthetic without epinephrine, at my own request by the way, because of previously getting palpitations with epinephrine.

    For my second round of extractions, I requested local with epinephrine and the dentist also wrote an Rx for xanax the night before and day of my appointment.

    The difference was like night and day. I was much calmer and I was able to get through the extractions with little to no pain. And to my surprise, I had no palpitations!

    I am proceeding along with the fittings for my partials. Then when the plates are completely ready, I will go in for the final four extractions and they will place the new plate right onto the fresh extraction sites. This is all new to me. I trust my dentist.

    By the way, I have been healing very nicely between visits.

    • Virginia, Your post was extremely helpful. I’m 68 and within the last year there have been so many dental problems due to ongoing Bone loss, over filled teeth, fixed bridges coming off with damaged teeth underneath! Are you getting implants for the dentures to be fixed to? If so, can you share your experience. I am facing some grim.choices and don’t think regular dentures will be comfortable and besides it scares me. I can’t afford implants and it’s awful that implants are never covered by insurance as they are considered cosmetic and hope a dental school.might at least be less costly. Thank & a doctor response is slso.appreciated. I also have sensitivity to epinephrine and will try Xanax before treatments.

      • Hi Gina,
        I am 67. As you probably read in my first post, I have a lot of bone loss also. My back molars were mostly all fillings. I have receding gums which also contributed to problems below the gum line and the bone loss too, I guess. They will have to do deep scaling on the remaining teeth and treat with Arestin, I believe it’s called. I will be keeping my own 6 top front teeth, my two bottom canines, and one root canaled molar with crown that I have on the bottom, so 9 of my own teeth. They will be making me partial dentures for the top and bottom. This is all a shock to me. I never dreamed that I would have to get dentures. So I understand your concern. I will not be having any implants, only ordinary dentures. I have never had dentures so I have a lot of fear of the unknown. I have to trust that it will work and that it will all be for the best. I am looking forward to being able to chew again as I have been without any back molars since they began these extractions a few weeks ago.
        I think you will do fine. I am afraid too, but I think nowadays they make better dentures and they should be more comfortable and look more natural than they did in the old days. Please let me know how you do. I will be anxious to hear about your progress.

  8. I’ve recently had 2 crowns put in. This required 4 different visits to the dentist; 1 visit for each tooth to get them ready and put the temporaries in, then1 visit for each tooth to put the permanent crowns in when they were ready.
    On the first visit, the dentist didn’t use any anesthetic at all. When the permanent crown came in for that tooth, I think he remembered how painful it was for me on the previous visit, so he gave me a choice to have anesthetic or not. I chose anesthetic.
    I thought he’d remember that choice for the next time, but no. Back to no anesthetic. I thought maybe there was some reason he couldn’t use anesthetic for that step. So for the next visit to put in the last permanent crown, I thought he’d give me a choice again as he did before for that step for the other tooth, but he didn’t. He just went in and did everything with no anesthetic. I kept thinking, maybe he’ll give it to me soon, but no.
    After the first visit, he said I should call them if the pain persists longer than a week or so. It did, so I called them and they had me come in. He only told me to give it some more time. He said it didn’t look infected or anything. So I gave it more time, taking Aleve daily and putting Orajel on my gums 2-5 times a day. The pain became less severe, but never went away completely.
    Now, after getting the second permanent crown, I’m still experiencing pain 3-4 weeks after the procedure and the pain has spread to my cheekbone, then to my eye socket. Co-workers are concerned it might be infected. If that’s the case, I don’t want to go back to that dentist, but I live in a very small town where he’s the only dentist nearby. Finding another dentist would mean driving an hour away.
    So is it normal to avoid using anesthetic to put in crowns?
    And is it possible my co-worker is right in thinking the pain in my cheekbone and eye socket may mean it’s infected?

    • Mark,
      Most dentist typically avoid using anesthetic when trying in a new crown. If the patient is numb, they are not able to effectively give feedback on how the crown feels, how the bite is, etc. Of course, if the patient is uncomfortable, we get them numb.
      Pain can radiate from teeth into the cheek and occasionally into your eye. Your dentist should do some testing to determine if the cheek/eye pain is originating from the teeth.

  9. I also recently had fillings on the lower jaw done with Carbocaine 3% plain, and, like all the other drugs, it DOES work if used properly, just like when I had my wisdom teeth taken out with it. My dentist told me that it is *just* as effective as Lidocaine on the lower jaw, but that many patients prefer it because the numbness wears off faster.

    Unfortunately, my dentist missed the block the first time, and so I felt everything! However, I simply raised my hand and he gave me another shot of Carbocaine. That second shot REALLY put the nerves to sleep.

    With that being said, it can also work on the upper jaw, but it will require more shots.

    • Thanks for the comment. No one is saying that carbocaine/mepivacaine is not effective. It is just less effective than local with epinephrine in certain circumstances. At any rate, glad you saw that local anesthesia in dentistry is not easy – some teeth and individuals numb up very easily – others don’t – and subsequently require different approaches.

    • Pauline says:

      I also have used Carbo Caine for root canal because the epinephrine didn’t let me sit still
      long enough for the dentist to work on me.
      My knees were shaking so bad , I couldn’t control my body shaking. So, no epinephrine for me but I do need to get a dental implant for one upper back molars and I hope I won’t need anything too strong to be able to go through the process.

  10. Trisha Diane White says:

    I’ve had extractions in the past, I’m sure they used epi in their injections, but never had no problem, I have to go Wednesday to have extractions again, if I didn’t have problems in the past, could I have problems this time?

    • You should discuss this with your dentist. Certain medical conditions, new prescription medications, and other factors may make it so that a local anesthetic without epinephrine is a better choice. Every case/patient is unique. However, 99% of patients handle local with epinephrine just fine.

  11. I first had no vocalize when I was 25 years old. The oral surgeon left me after the injection to give time for my mouth to numb. After a few minutes my heart started racing and beating out of my chest, I had trouble breathing , the room was spinning and I was so blurry and felt like I was going to die. I tried but could not get anyone’s attention because I could not speak and I felt like I was floating. The oral surgeon came back to check on me and he immediately reclined my chair with head down and feet up and administered oxygen and after several minutes I was ok. This happened years later and that’s when I realized that I could not have that medication. I was told casually by another dentist my mom had that it could be the epinephrine. My next dental apptreatment went good with another dentist that I told no epi…but the following apps when I said no episode they gave it to me anyway without reading my paperwork and the had to call 911 because I began to shiver uncontrollably, I became very cold and could not breathe. Sour I went to the oral surgeon who sent me to a specificit list who tested me with many different drugs of the sort. I did not know which had episode in it or not…It was found that the epinephrine was my problem. I don’t call it an allergy but an adverse reactions to epinephrine. When they gave me lidocaine in the ERROR to remove a fish hook from my finger I had the same reaction but not nearly as severe because it was a much smaller dosage. Now I request Carbocaine at my dental visits and it has been perfect. The episode just makes the anesthetic last longer I think.

    • I meant no vocalize in the first sentence..sorry. I should have proof read. I see typos.

    • Laura,

      I wasn’t there for any of your episodes. However, the first episode matches the textbook description of vasovagal syncope (a.k.a. fainting). Vasovagal episodes are quite common in the dental office. The stress of having many hands in your mouth, the prospect of pain, and long needles all have that effect on people. In these episodes, your own body releases FAR more epinephrine than what is injected in you.

      I am glad that you characterize your experience as having an adverse reaction – as opposed to an allergy – because it is impossible to be allergic to epinephrine.

      • It’s too simple to state it was vasovagal syncope and actually, it doesn’t sound right for that anyway.
        Remainder of post removed

        • Annie,

          I deleted the bulk of your post because all you did was talk about your own experiences as opposed to offering any helpful commentary to the OP.

          If you read back to my response, I started with:

          “I wasn’t there for any of your episodes”

          I don’t think you need me to elaborate. But basically, since I was not the treating provider, nor was I there for the procedure, it is impossible for me to know for sure.

          I stand by my initial thought that the first episode was likely vasovagal syncope. Reasons:

          1. Of all the “emergencies” that occur in a dental office, vasovagal syncope is by far the most common one. 53% according to one study of over 50,000 emergencies.
          2. When a syncopal episode does occur, the most common trigger, by a LONG shot, is the injection.
          3. Tachycardia, difficulty breathing, and visual disturbances – all are pathognomonic for vasovagal syncope. These are exactly what this individual experienced.
          4. Treatment for syncope is EXACTLY what the individual said the oral surgeon did. Reclining the chair with the legs at a higher level than the head is the treatment, along with supplemental oxygen.

          If you still believe that syncope is “too simple” of an explanation, that’s fine, you are entitled to your opinion. But I’ll note that you failed to propose an alternate diagnosis.

          • Note:
            The following commentary is being posted, even though it is largely off the subject of the original blog post.

            My comment was not intended to be specifically in response to the comment above, but to point out that, unless medically – not dentally, qualified, it would be very hard to make the distinction between a faint and a POTS related adrenaline issue. There are different types of POTS and for some patients the only obvious effect in the dentist’s office may be syncope, which will look very like your typical vasovagal episode, but that episode can trigger weeks of severe symptoms as a consequence. So while not a life-threatening event, it’s obviously something that still needs to be prevented.

            EDS is a little different, for EDS patients the concern is not syncope, but the effectiveness or rather lack of effectiveness of pain relief.

            You state that “Of all the “emergencies” that occur in a dental office, vasovagal syncope is by far the most common one. 53% according to one study of over 50,000 emergencies. …
            When a syncopal episode does occur, the most common trigger, by a LONG shot, is the injection. …Tachycardia, difficulty breathing, and visual disturbances – all are pathognomonic for vasovagal syncope. These are exactly what this individual experienced.”

            My point is that what appears as a simple vasovagal episode to the dentist may have further reaching implications for the POTS patient and yes, the shot is usually the trigger, although some POTS patients may also struggle and become symptomatic if postural changes are necessary during the procedure and on rising at the end of treatment. In both cases the patient will respond to the usual vasovagal treatment (although generally a large glass of water to increase blood volume would also be a big help) but the consequence of that ‘faint’ may take weeks for them to recover from. For POTS patients with a hyperadrenergic state, the consequences could be more serious, but as the condition is so rare, most dentist probably still wouldn’t realise the reaction was down to POTS.

            Obviously I don’t know for certain, but I’d hazard a guess that the study you mention didn’t give consideration to POTS and the study probably wouldn’t have covered longer term effects, most of which would seem unrelated to someone unfamiliar with autonomic dysfunction.

            Lots of people have cited their own experience on here and they haven’t been deleted. The only reference I made to my own experience was that I have two disorders that contraindicate the epi. I didn’t mention my own experiences at the dentist. My post was to raise awareness that these conditions need careful consideration and alternative methods of pain relief for dental work. In the case of POTS, in some cases, using epi could cause a serious episode, for others weeks of severe symptoms and in EDS local anaesthetics may fail to work or not work effectively enough. This information is something that is little known at present, even by people that have been diagnosed with the conditions and many people, such as myself, feel it is important to raise awareness. I came across your blog while researching dental work without epi myself and commented as there was absolutely no mention of either disorder, which I found odd, given they are two good reasons for choosing not to have the epi..

            I can only assume by your refusal to include any reference to POTS or EDS that you aren’t interested in learning how these relatively newly recognised conditions can adversely affect dental patients. If you are, there are plenty of sources on the internet to read up about it and I suspect more in medical journals to which I don’t have access. I don’t have time at present to dig out the ones I’ve studied, but even a quick Google throws up the following:

            http://www.dinet.org/index.php/information-resources/pots-place/pots-what-to-avoid

            https://uthealth.utoledo.edu/clinics/hvc/pdfs/Postural%20Orthostatic.pdf

            http://www.iosrjournals.org/iosr-jdms/papers/Vol14-issue5/Version-3/E014532326.pdf

            http://www.ncbi.nlm.nih.gov/pubmed/16637478

            Presentation on considerations for dental work on EDS patients. Anaesthetics are discussed at about the 31 minute mark. http://www.shareswf.com/game/33631/dr-carl-mentesana
            (Note: I watched this portion. The speaker takes a very simplistic approach and makes some pretty broad generalizations. But he is correct that buffered local anesthesia – which I use – can help EDS patients).

            The speaker has also discussed different types of local anaesthetics here http://www.chronicpainpartners.com/doctor-speaker-series-december-4-2013/

            I find it very disappointing that raising awareness of these very real medical implications for dentistry are regularly so easily glossed over and ignored. I don’t expect you to post this comment, but wanted to clear up my reason for posting and will now leave it there.

          • Thank you for the long comment.

            Contrary to what you might think, most dentists are aware of orthostatic hypotension. While I don’t have any studies to reference, I would say that my hygienists and I see about 5 patients per day who have the potential to develop orthostatic hypotension – and those are patients who take anti-hypertensive medications. So, while POTS may not be known to many dentists, the concept of decreased cerebral blood flow (with then a reflex tachycardia kicking in to compensate) as a result of bringing the patient upright is generally known.

            I believe it is unfair for you to characterize me as not “interested in learning how these relatively newly recognised conditions can adversely affect dental patients” simply because EDS and POTS were not included in this post. If I were to include every single detail, condition, and/or nuance in every post, then each post would be over 2000 words. And Google would simply not index it as it does now – and most people would NEVER even be brought to the post. No where in this post did I imply nor state that this was an exclusive list. I am not glossing over these conditions nor minimizing them. If I were to include every single nuance/condition, I would have to write a textbook.

            Regarding EDS, the most recent article on this site (http://directionsindentistry.net/dental-local-anesthesia-ehler-danlos-syndrome/) is about EDS. So by all means I am aware of that condition. And I will agree that most dentists know little to nothing about EDS.

            So, I applaud you for taking charge of knowing your conditions. However, I would caution you in how you approach your providers. I am unlike most other dentists in that I love to discuss pharmacology, physiology, and other details with patients. As such, I attract many patients who were normally frustrated with their dentists. Remember that this is a two way street: if you go in with a list of demands, refuse to listen to this/her expertise/experienced, and are unwavering in your demands, you may be politely shown the door.

            Lastly, I would be curious as to why you believe epi should not be used in patients with EDS. I spent significant time researching my last EDS article. Unfortunately, there is little information on why EDS patients do not experience adequate local anesthesia. The going theory is that because of the collagen defect, the local diffuses away quickly. What better way to counteract than to use a vasopressor such as epi? Please leave a comment on the EDS blog post if you are inclined.

  12. I just came from the dentist and had injections with epi. I have had it before with no problem but this time I got the “jitters”. Had my dentist check my pulse and determined it was normal. She indicated that some people have this reaction and I had not eaten. It passed within a few minutes. We knew going in that I might have trouble getting numb as I had just seen her the day before and she had started me on antibiotics. Had to do the extraction as the tooth we were going to extract next week broke in half last night. She warned me we might have trouble with the numbing. We did but just kept testing areas and finally even though there was momentary pain, it is out!

  13. I am getting my lower right back tooth extracted this Thursday and the oral surgeon is going to put in an implant. That tooth has been giving me trouble for some time, and last Thursday it finally blew up on me. I am on penicillin for now. It is not as bad as it was, but still very painful and my whole right bottom jaw is in pain. Is that probably from the tooth pain? I am a non epi user, but after reading your posts I think I might use the epi this time. I think the whole procedure will take 1/2 hour.

  14. On May 8 I had a Pons Hemorage. A small one, that left no lasting symptoms or degradation of function. I spent 24 hours in ICU as a precaution and running many tests, Cat Scans, MRI, blood tests, cardiac function….etc. which tested fine but evidence of previous pons leaks that were tiny and unknown to me. Hypertension is the reason and although I have taken medication for years, my blood pressure has obviously not been adequately controlled. I have a broken molar including a deep cavity, therefore the tooth needs to be extracted. Dentist says this lower molar cannot be removed without pain unless novacaine with epi is used. Neurologist says not to use epi as it will cause blood pressure to rise. Obviously pain would also add stress to an already stressful procedure and reaction to adrenaline concerns me also. Now just the discussion of all of the possibilities puts fear into the procedure for me. I don’t know what to do. Right now, I have no pain in the tooth but that could change at any moment. During the exam today, upon sitting upright again, I experienced a fair amount of dizziness. For now we have the extraction scheduled for early July 2016, about a month from now. (I am 67+). What should I discuss with both doctors? Advice?

    • Vicki,
      This is a very serious issue and you need to bring it to the attention of both the neurologist and the doctor removing the tooth. The dizziness is likely orthostatic hypotension but again I can’t diagnose you since I am not treating you.

  15. Suzette says:

    Starting about a month ago, I experienced throbbing and toothache like feelings in my upper right, #3, and possibly #1 molar(s), the #2 molar is extracted. This pain was on-n-off for two to three weeks. Both of these teeth had extreme gum line recession. And, the right #1 molar has a crack (don’t believe the crack is all the way up the tooth yet), and is filled with amalgam. The #3 molar also is filled with amalgam. I saw a new dentist, had x-rays, which I don’t believe showed anything. I asked if she would do bonding on both teeth, to see if this was the problem. I cannot tolerate epi, so I had the procedure done without anesthetic, and it was almost unbearable, but I made it through. It’s been two weeks, and two days since that procedure, and my pain has gradually gotten better and better, but not quite gone. I have an appointment tomorrow to have a prep done to put crowns on both these teeth. First question: Do you think I should wait for the crowns? The dentist recommended crowns on both teeth. Since I cannot tolerate epi, she is going to us Citanest plain (no epi or adrenaline). Is Citanest a good choice for anesthesia?

    Thank you.

    • Citanest Plain – which is 4% prilocaine – and 3% carbocaine (generic is mepivicaine) are the two most common local anesthetic formulations in the U.S. that don’t have epi in them. Both are fine for patients who want/need local without epi. The only downside is that you often need more injections and in some cases it can’t be difficult to get a patient profoundly numb. For crowns, I would definitely want to be numb, so the Citanest should work.

      • Suzette says:

        Thank you for your response, much appreciated! I had the prep done yesterday, using Citanest, and all went really well. However, after Citanest wore off, I was in great pain throughout the rest of day and night. Today, the pain has subsided. I guess I won’t have fear of anesthesia using Citanest in the future… very happy about that!

        By the way, I can’t have ANY adrenaline in my anesthesia, as I stated Citanest worked great.

        Thanks again,

        Suzette

      • Suzette says:

        Thank you for the quick response. After I had the prep for crowns, and had temps placed on my two teeth, I experienced a whole lot of pain; aching and throbbing throughout the night, which subsided the next day. However, my CNS is compromised, and therefore, I was very nauseated, sick to my stomach, and felt very ill for four days, which as each day passed got better and better. I am now due to go back to my dentist to have the crowns placed, and I must say, that I am somewhat fearful, as I know if I need anesthesia again, I will most likely, suffer the sickness I felt from the prep and temps. If you have any suggestions, please let me know. My appointment is in three days.

        Thanks again, much appreciated!

        Suzette

  16. Melda Adlem says:

    I use atenolol for high blood pressure. What dental injection should I ask the dentist for? My tooth needs to be pulled.

    • Atenolol is a cardioselective beta blocker. Generally speaking, and I am generalizing here, patients on cardioselective beta blockers (as opposed to non selective) are able to tolerate epinephrine – assuming there are no other medical conditions which might make epinephrine contraindicated.

      As long as your dentist is aware of your current medications, you should be OK – he/she will make the correct choice.

  17. Dr. Thank you for having this blog and giving us good information. When you have time could you give me some insight?

    I have a chronic abscessed tooth (that’s the upper right one behind the canine tooth), that’s underneath a bridge. For the longest time I thought I had a sinus infection, but it was the tooth. Doc said it was so decayed it’s gotta go. I noticed the fistula two weeks ago and I started feeling really lousy. Just no energy. So I’ll be glad to see it gone so I can feel normal again.

    I’ve not had an extraction in 30 years and I’m so nervous. The dentist has me on Flagyl and Clindamycin (sp?) for the infection. I’m having an extraction Friday.

    Here’s where I’m nervous. 30 years ago I didn’t have elevated Bp. Now I do. Well I control it with meds, losing weight and cleaning up my diet, but I’m not all the way there. I take my BP every day, I monitor it at home. It appears to be higher with this infection (135/80 vs. now 145/77). I’m worried about the epi racing my heart.

    I asked my dentist if he could give me the other stuff, carbocaine (I believe it is). He sure but there is a little more bleeding and less numbing. I’m thinking the tooth is so decayed, it will just fall out. I’m going to have a Valplast partial for the two missing teeth.

    Is it your experience that patients taking BP meds fare off bad with Novocaine or should patients go on Carbocaine for numbing? My doctor did give me xanax to take the night before (1 mg, I took .5 miligram and I was sufficiently relaxed) and one an hour before the extraction.

    Your insights please.

    Thank you Debbie.

    • Debbie,
      You probably already had the extraction.
      Generally speaking, a couple of blood pressure medications along with slightly elevated BP is not a contraindication to using epi. But every case is different.
      What is more “dangerous” would be for you to feel pain. If you felt pain, you could be sure your BP would elevate very quickly due to your own epi being released. So, in these cases, profound local anesthesia is probably the most important factor.

      • Hi Dr. Calcaterra! Thank you for getting back to me. I appreciate that.

        The extraction went off without a hitch! I took .5 milligrams of Xanax the night before to get a good’s night sleep (which was hard as I was very nervous) and .5 an hour before the extraction. I was pretty relaxed when I got into the chair.

        He did give me carbocaine (SP?) and I didn’t feel the slightest bit anxious at all and my BP didn’t shoot up. The nurse gave me a numbing agent on a cotton ball and a few minutes later I got the shots. Felt a little needle prick but hardly any pain. The numbing lasted throughout the procedure. I didn’t even feel him tugging me. He sawed off the bridge and saved the back tooth on the bridge. He wiggled the bridge and the tooth literally fell out. It was badly infected.

        I feel a 1000% better. I was feeling a lot better before the appointment just reading your blog.

        Thank you for your kindness and your dedication to scaredy cats like me.

        • Debbie,
          I am glad things worked out. Sometimes, patients will get all worked up over a procedure, and that makes things worse. Sounds like you tolerated it well. And hopefully, you’ll be a little less scared next time.

  18. Suzette says:

    Since my last email, using Citanest turned out not to be good for me, as I felt very sick for about five days afterward, which gradually subsided. However, not using adrenaline did stop the panic feelings.

    Last Wednesday, I had my crowns placed; one on the #2 molar, and one on the #4 molar. It’s four days since, and I have bite problems, etc. PROBLEM with #2 molar: it is too big, and it rubs too much against my tongue and cheek. There is too much pressure on bite. I did tell the dentist, at time of visit, that I felt the tooth was too big. She told me the porcelain fused to metal will make the tooth larger. I have to go back and ask her to file down the bottom of the tooth and the back and front of the tooth. PROBLEM with #4: When I bite down, I feel my bottom tooth hitting the upper bottom of the crown. When I feel the bottom side of the crown with my tongue, I note that the small space provided for the lower tooth (which is pointed) to sit properly is not long enough. These problems are really irritating.

    I am gong to make an appointment to get the crowns adjusted, however, my fear is that since I have porcelain to metal, I’m not sure if the dentist will be able to file off enough of the #2 tooth without causing problems, and that is one of my questions. If the #2 crown cannot be fixed properly, will I need to have another made? And, if so, how are these crowns taken off? I wish I was given information regarding each crown before choosing, but I was not. Now that I know, I would have opted for the gold alloy.

    Thank you again for listening, and I value your opinion and advise.

    Suzette

    • Suzette,

      You certainly should inform your dentist of your concerns over the bite after the crowns were inserted. The rest of your questions are too difficult to answer without examining you personally. Once a crown is cemented on, it can’t be removed without drilling it off – and thus destroying it in the process. This procedure is nothing to be afraid of – but certainly if it can be avoided then that would be ideal. I hope this helps.

      • I had my follow-up visit with my dentist a week ago (last Wednesday). She drilled down quite a bit of crown #2, almost down to the metal underneath. She did not fix the bite of #4 crown, which is hitting my lower tooth. She didn’t want to take out anymore of the crown. Well, since than, I have the same problems to a slightly lesser degree, but it is annoying. I will let this go until the end of the month, in hopes that I will get use to the rubbing of the crowns on my tongue, and the upper crown hitting my bottom tooth. If she can’t fix these crowns properly, can I have them done with no cost to me, as they were very expensive?

        Thank you.

        Suzette

  19. I had a mole removed from my forearm a few months ago for a biopsy. I was given a very small amount of lidocane and epiphenrine for the procedure, they said afterwards it was 1cc. I had the following symptoms during the procedure and they came on one at a time. First I felt dizzy, then I was nauseous, then my throat felt tight and I had a metallic taste in the back of my throat. Then my chest got really tight and finally towards the end of the episode I got very cold. All these symptoms subsided after about 30 minutes except for the coldness and some mental confusion which lasted for a few more hours. The only thing the staff kept saying to me is ” I thought you said you had dental work done before”. Which I have. After the procedure they told me to tell everyone from now on that I have a sensitivity to epinephrine. I am hypothyroid and take medicine for that, along with some other health problems but the only heart problems I know of are atrial and mitral value prolapse. I am now faced with a dilemma, my lower first premolar is chipped and needs to be extracted. I am considered low income and I have no dental insurance. I went to one dentist and told her what happened when I had that shot. She said she would not treat me until I was allergy tested for lidocane and epinephrine and I brought in a note saying I was not allergic. They told me that to get anything other than a shot would be iv sedation and that would $1200.I went to my doctor to get allergy tested and she said there is really no way to test for an allergy to those medicines except to give them to me and to see what happens. Is there a cheaper alternative to iv sedation that you know of or something else that you could suggest? Thank you, Kell

    • Kell,

      That sounds like quite an ordeal.

      A true allergy to lidocaine is very rare but possible. I wrote a three part series on this starting here: http://directionsindentistry.net/novocaine-allergy-part-1-esters/

      What your reaction was at the dermatologist is hard to tell. But generally speaking, if it were an allergy, there likely would have been findings that the injection site. Meaning more than just a small lesion from the biopsy.

      I am not sure what your physician said but an allergist can test you for an allergy to lidocaine, methylyparaben, and bisulfite – all of which were likely parts of the injection you received at the dermatologist.

      Hope this helps.

  20. Christine says:

    I think that this is total BS. I had, at the age of 66, my very first pain shot of epinephrine today. My heart immediately began racing and pounding and I felt pressure on my chest. How is it that I have been to numerous dentists over the past 66 years and no dentist ever gave me epinephrine before??? So when I come to Seattle, I get my first shot of it?? It is completely unnecessary. The attendant who administered the shot said nothing about this effect. When I mentioned it, she said: “Oh, that’s completely normal. You’ll feel fine in about 3 minutes.” Well, it lasted at least 10 minutes, 10 SCARY minutes! It is never ‘normal’ when your heart is doing somersaults in your chest! Dentistry should not be promoting this stuff. They should be sued for using it and for causing obvious stress to the heart.

    • Christine,

      I was not there for your visit in Seattle nor your previous visits. But I’ll offer my own explanation:

      You’ve received local anesthesia containing epinephrine previously. But at this Seattle visit, because of your own anatomy, you actually experienced some going into your bloodstream, and as a result, you felt those unwanted effects.

      You are more than welcome to request local without epi.

      To say it is “completely unnecessary” shows that you don’t know much about the subject on which you are writing.

      Dentists “should be sued for using” epinephrine?? People make statements like this and then also complain about the skyrocketing costs of health care. Maybe there’s a correlation there…

      • Christine says:

        Thank you for your reply, Dr. Calcaterra. Of course I don’t know much about the subject on which I am writing…I just know what I FELT and I ALSO know that for 26 years of my life I had an excellent dentist who never gave me so much as a shot in my mouth…so I maintain that giving this epi stuff IS, indeed, completely unnecessary. At the very least, patients should be forewarned of the possible effects BEFORE being shot up with it! I think that what epinephrine does to enhance pain control is not worth all the side effects that people complain about.

        The woman who gave me the 8 shots, 2 in the roof of my mouth, gave me no ‘head’s up’ about what I might experience. As I am having my mini heart attack, she is making jokes about using the defibrillator in the back on me. Very funny! Then she tells me that my reaction is ‘completely’ normal, especially for redheads like myself. ‘Normal’? Would someone actually make an appt. for a dentist KNOWING that they were going to experience a racing heart and chest pressure? (Not ME!) I take metoprolol to keep my heart from doing just that! So I called my long-time dentist back in New York and he told me she had done too many quadrants at a time. (I was also told that assistants usually do not give shots…that that is something for the doctor to do. True?) Even with all that stuff in my system, the doctor STILL hit a nerve in each tooth! It was about 20 minutes before he actually got to me so I guess the shots had worn off by then.

        No, I don’t know much about the subject on which I am writing but, as I said, I know what I felt and I refuse to ‘buy’ the (apparently) standard line that it’s perfectly normal and harmless. Causing your patients’ heart rate and blood pressure to artificially elevate may be ‘normal’ after being shot up with epi…but it cannot be healthy for the heart and is certainly not pleasant. Yes, in a life and death situation, give me epi to get my heart going again…but don’t give it to a healthy individual who is just getting her teeth worked on.

        I have found the medical profession to often use bad judgment and no one can convince me that some patients have not had more serious effects from causing stress to the heart. One has only to read the comments on pages like this to see the adverse side effects patients experience. One elderly man said he was sure that it caused him paralysis on both sides of his face and a stroke because it happened as soon as he came home from the dentist after getting those shots of epi. He felt sick to his stomach, laid down and his face went numb. He next found himself in the hospital. No correlation? Of course the dental association is not going to admit to any cause and effect.
        T
        Thanks to the medical profession, I had to have a mastectomy at the age of 35 b/c they kept telling me I was too young to have breast cancer. I saw 3 doctors who all concurred. A mammogram and ultrasound came back normal but my lump was still painful and growing. (Oh, and doctors say lumps are usually not painful! Wrong again!) After nearly a year of walking around with the lump in my breast, I insisted that something be done. It took a nurse practitioner to take me seriously. He referred me to a surgeon who took out the lump and said it was indeed an aggressive cancer for which I had to have 4 months of chemo and a mastectomy. Had they taken immediate action, I could have gotten by with just a lumpectomy and radiation. I, stupidly, was counting on my doctors to give me the best advice. So, doctors are not infallible, I went back to the place where they had done my ultrasound and mammogram and my records had mysteriously disappeared!! So if doctors are afraid of being sued, they just get rid of the evidence. Lesson learned.

        In the future, I will make sure epinephrine is not given to me, now that I know what it can do to me.

        Having said all that, I appreciate forums like this where dialogues can take place between doctors and patients. Thank you.

      • Christine says:

        Furthermore, I would go so far as to say it is irresponsible for the dental profession to just shoot up people with epinephrine without telling them of the possible side effects and giving them a CHOICE. I would expect a dentist or dental assistant to say: “Christine, have you ever had epinephrine before? Me: I don’t know. Dental assistant: Well, you MAY feel your heart racing and a slight pressure on your chest but this is not harmful to you. The epinephrine we give you is very low dose and helps with pain control. Would you still like it? Me: No thank you.”

        THAT is how a responsible dentist’s office should handle giving their patients drugs that they may be unfamiliar with and may have an adverse reaction to. I think the dental profession is too cavalier in this.

        P.S. I have never sued a doctor but sometimes, with the ridiculous mistakes they make, they deserve to be sued. One woman in my hometown of Erie, Pa had the WRONG breast removed! Wow!

  21. Christine says:

    One last thing…honest! I now know, after perusing these forums, that I do have a choice. I didn’t know that before b/c I had never had this experience and would have had no reason to question it. I’d rather experience a little more pain (rather than to take a drug that effects my heart.) I gave birth, for god’s sake and I have had 5 kidney stones. Now THAT’S pain 🙁 !!

  22. Perhaps there is no “allergy” to epinephrine but it doesn’t mean individuals don’t have a severe reaction to it. I’m a very healthy 52 yr old female. Diagnosed with PVC a couple of years ago. Premature ventricular contraction. A rather mild condition that demonstrates the electrical current of the heart. PVC has no apparant effect on me UNLESS I consume caffeine on any level. Even the smallest dose. Took me a couple of years to figure out that it was my weak cup of green tea making my heart do back flips. I even need to monitor chocolate. Otherwise zero recognition of it. HOWEVER, I will tell you, novicaine with epinephrine has sent my heart into a very rapid and irregular heartbeat that wasn’t pleasant. So, there are grave effects for some people.

    • Michelle,

      I am glad you understand the difference between an “allergy” and someone simply being sensitive to a drug.

      A rapid and irregular heartbeat can and will occur with administration of epinephrine should sufficient quantities of that epinephrine reach the myocardium. Again, this is not an allergy. Your heart is SUPPOSED to respond to epinephrine.

      I am personally very knowledgeable about treating patients who experience PVCs. Your description of PVCs if slightly inaccurate but there’s no sense in addressing that. If your own dentist does not know what a PVC is then it might be time to look for a new one.

  23. Christine says:

    Just heard about the toddler who died under anesthesia at Austin Children’s Dentistry. What on earth is a dentist DOING putting crowns on baby teeth in the first place??

    It has been determined that it was an anesthesia event which led to Daisy’s death…not the dental work…but how much anesthesia…or how long would Daisy have needed to receive this anesthesia… in order for 4 crowns to be put on? I will follow this one closely.

    • Christine,

      I do not know the specifics of that case so I can’t comment on it other than the fact that this is a tragedy. But let me tell you about some things that the media conveniently neglects to report:

      Each year, thousands of toddlers are hospitalized for severe dental infections, resulting in multi-day hospital stays, dozens of tests, radiation exposure from x-rays and CT scans, the development of antibiotic resistance, etc.

      Nearly all of those cases are due to parental neglect. Baby bottle tooth decay is neglect plain and simple.

      If the toddler had gone to a dentist with an abscess and that dentist had basically said “I can’t help her because that requires general anesthesia” and then 2 days later the toddler dies from that infection, the media, and possibly you, would be up in arms wanting that dentist to be sued for not treating the child.

      Even in 2016, toddlers, teenagers, and adults die from dental infections:

      https://www.washingtonpost.com/local/5-years-after-boy-dies-from-toothache-maryland-medicaid-dental-care-is-on-mend/2012/02/15/gIQANEJoGR_story.html

      A dental abscess in a young child, especially one with an abscess with a top tooth, is literally less than 2 inches from the brain. That should scare you and any other parent.
      This is why toddlers are given general anesthesia to address dental problems

  24. I’ve got a badly decayed lower second molar. The crown of this tooth is completely gone, and it’s starting to break down below the gum line. It’s also constantly infected, and tastes truly appalling. The problem I’ve got is I have a severe phobia of needles. Is it possible to remove teeth like this without numbing injections? Pain doesn’t bother me. I’ve had all my fillings done without injections, and some of them where rather deep.

    • Cara,
      It is very rare that a tooth – or what remains of a tooth – can be removed without local anesthesia.
      I’ve had this request several times over my career. In all cases except one, the patient was asking for local anesthetic after 5 seconds.

      • So I will just have to learn to live with it in my head? I can’t allow needles anywhere near me, so local anesthetic and sedation really isn’t an option. Are there any alternatives to the injections?

        • Cara,
          Your best bet is to be sedated. I do this in my office with needlephobic patients:
          We give you a relaxing pill the night before.
          You then take a relaxing pill an hour before.
          You are very relaxed once you arrive.
          We give you more relaxing pills and/or laughing gas in the chair and then start an IV. You won’t even know nor care about the IV.
          We push IV meds, get you numb, the tooth come out, and then you slowly emerge and come back to reality.
          Case closed.

          • The problem I have is oral sedatives have no effect on me at all. It’s been attempted, but they don’t make me relaxed or sleepy. I am very much awake and alert, and I still can’t tolerate injections of any sort.

      • Kristine krawczuk says:

        I disagree, ive had a root pulled out after my tooth broke off, root fillings done with very slight twinges and bridgework done with no sedation or numbing agents.
        Kristine

        • I’m not really sure what you’re disagreeing about. You are more than welcome to have procedures done without local anesthesia. I’ve had several patients over the course of my career make that request. As long as they’re informed of the risks, I typically go ahead.

  25. I came across this when searching for whether it’s possible to have a cyst on my back removed without using epinephrine (I’ve had them removed before and they keep coming back). I have POTS and already have severe tachycardia, and the times I’ve had local injections, it’s felt like I’ve had a hummingbird in my chest. My dentist wasn’t aware about the interaction between local anesthetic epinepherine and beta blockers, especially non-selective beta blockers. It can cause the unopposed alpha effect, which can result in uncontrollably high blood pressure, even in someone who never previously had high blood pressure. I have to be very careful about this because if I don’t ask every single time, they default to using epinephrine. To the author, I *have* to say allergy because they will not notate it on the chart. I know it’s not an allergy. It is, however, contraindicated and they don’t remember. It also has very severe interactions with non-selective beta blockers. To say that of course no one is allergic because everyone has endogenous epinephrine is true, but many people have to take drugs to block endogenous epinephrine from over-activating their autonomic system. The anesthetic without it definitely does wear off faster and we have to re-inject sometimes. I just can’t find any information on whether this is possible for a surgery on the back to remove a cyst. I had it done 8 years ago and my heart rate was 180 bpm and I was shaking uncontrollably. He swore up and down it would have no bad effect. I knew from previous dental experiences it would, but it had been infected, so I had no choice. When I had the bad effects, the dermatologist left me by myself in the room. I think he panicked not knowing what to do. I just lay there for about a half hour until the shaking wore off, and he finally removed the cyst when I stopped shaking enough for him to do the work. Fortunately I was still numb. If anyone coming across this knows of a way to do this for a back cyst without epinephrine, please let me know.

    • Marcus,

      I appreciate your long comment as well as you knowledge on the subject.

      You have obviously concluded, correctly so, that your reaction to epinephrine is not allergic in origin. But, as you note, it doesn’t mean that it should be used. There are many commenters on this other article (http://directionsindentistry.net/dental-mythbuster-allergic-epinephrine-allergy/) who still believe they are allergic to epinephrine though.

      Back when I was a resident, I did a rotation in the ER, and we did a lot of extraoral suturing of lacerations. Ears, necks, fingers, etc. There are many areas of the body that you should NOT use epinephrine. The external ear, because of its poor blood supply, we used 2% lidocaine. No epi. In fact, when I start IVs on patients for sedation, I inject a little 2% lidocaine so they don’t feel the IV needle.

      So, even though I can’t comment on the dermatologist’s preference, it is quite normal to use local w/out epi in certain procedures.

  26. I have a cavity clean up on lower left molar and upper left molar. I was asking the doctor to use the waterlase. She is willing to try untill it hurts after which she may give me local anesthetic. I have a neurological issue, which is why I want to avoid any ansethetic for fear of any facial paralysis. Which anesthetic would be better suited for the same.

    Thanks

  27. I noticed over the years that the shots with epinephrine were causing stronger and stronger reaction ions. I don’t fear the dentist at all so I get tired of that BS as an excuse for my reaction to the epinephrine. I get that you can’t be allergic but it doesn’t mean some of us do t have some kind of metabolic reaction that is uncomfortable!

    I’ve successfully been treated numerous times with epinephrine free shots many times. My dentist knew I didn’t want any epinephrine. About 20 minutes into being prepped for a crown, I had a weird feeling in my calves. I asked if I could have a reaction to the shot and was told no. It felt like dozens of butterflies were inside my calves, fluttering and trying to get out. Then I began to shake uncontrollably and pretty violently. The dentist asked if there was anyone I wanted him to call? I joked and asked, “why, am I going to die?” Heart was racing. I felt like I could breath fine but it was like my brain wasn’t getting oxygen. I started to turn inward and focused on long deep breaths to keep cam and get through it. Wasn’t sure what the hell was wrong until he finally confessed that the floss he wrapped around my bloody gums was soaked in epinephrine. I think it got into my bloodstream. Whole episode lasted about 3-4 hours. Then he blamed me for not being absolutely clear I couldn’t have epinephrine? I was very clear about it! Jerk! I could see on his face as well as his helper, that my reaction was scaring them. I am not allergic and I’m not anxious about the dentists. But it sure was the worst reaction I’ve ever had.

  28. So I just read an article about contraindications for epinephrine, (following after this) and it kinda confirms what I have felt was part of the problem. I am sensitive to sodium metabisulfite. I ended up in hospital, in college, with severe gastritis due to eating 3 salads where I had worked. I had that day spent an hour with bare hands, sprinkling some kind of sulfite powder on heads of lettuce to prevent browning, then I processed the lettuce for salads. I was told i had gastritis. I vomited and was doubled over in extreme pain. I thought I was having appendicitis.

    Since then, I’ve become very ill when eating foods with sodium metabisulfite. Figured it out after eating coconut macaroons once and eating Crab Shack coconut shrimp. The sweet coconut has sodium metabisulfite. Many canned and jarred products have it as well as frozen shrimp. Go figure! Well, lidocaine and epinephrine also have it as a preservative.
    I know back in early 80’s sulfites were removed from salad bar foods due to some people having anaphylactic shock from consuming those salads with that preservative. I don’t know how closely related sodium metabisulfite is to sulfites on salad bars but I suspect it may be why I react so severely to epinephrine.
    It’s a lot easier to suggest patients have “anxiety” though, which ticks me off!

    Contraindications to epinephrine and lidocaine
    https://www.drugs.com/pro/lidocaine-and-epinephrine-injection.html

  29. Hi. I have 3 back teeth that need to go. One which is so broken that it will have to be removed surgically. All are infected and due to allergies, antibiotics aren’t an option to control it. I’m also a cardiac patient with svt and short bursts of vtach. No dentist wants to touch me so what the heck do I do? This can’t stay this way. I have had the epi shots in the past with no issues. As bad as it seems I am desperate enough to not disclose my med history to a new dentist. Do you think I should chance the novacain in this situation? Thank you.

  30. Hi doc,
    I have anxiety and PTSD. I went to the dentist in January of 2016 to have a tooth checked out and to have one of my upper wisdom teeth (which had been crumbling) checked out and he recommended we remove the wisdom tooth first. I was nervous, so he injected me with a lot of lidocaine. About three vials worth (I have pictures). We got the tooth out but by the end of it I was shaking like a leaf and my heart felt like I had run 5 miles. He said all was normal.

    I went home and proceeded to have the worst panic attack of my life that lasted for 4 hours. I literally felt like I was going to die, it was not pleasant. The hypervigilance was extreme. I managed to get over it but after a reoccurrence of this panic attack (about 5 separate occasions in the same week) I started to lose complete autonomy. in short, I ended up losing a year of my life stuck in the house with extreme anxiety.

    Now the time has come for me to get to a dentist again but I am truly scared. I have a hole in my left upper 2nd molar and my bottom molars (same side) have become extremely sensitive to hot and cold. I am going to go to the dentist and defer to their recommendations but I can’t help but feel nervous. I realise that for my upper molar they will recommend a root canal. I cannot do it. I will ask them to pull it. I will not be able to be in the chair for over 30 mins. Similarly, as I have depersonalisation, other types of medicating are completely out of the question.

    I am really at an impasse. I have no problem getting a filling for my bottom tooth, at the very least. My PTSD and anxiety were completely unrelated to anything with going to the dentist, to be clear, I was already like that prior to visiting the dentist but that visit exacerbated what was already there- I had been managing myself quite well, was able to go to work and go out with friends and exercise as normal. It has gotten me back into counseling for sure.

    Any advice on what to do here would be great. I will have to opt for any epinephrine free anesthetic, but at the same time I have become extremely wary of medications- to the point of refusing to take even Motrin for extreme headaches. It’s just a no win situation that I will have to go through and hope for the best.

    Sorry for the long post and thanks in advance for any helpful advice.

    • David,
      That is quite a story. You clearly have your hands full. I know that you are against taking medications, but I would strongly encourage you to consider being sedated. If you consent to that, it will likely be the best thing to get through the needed procedure.

  31. I have asked my dentist on several occasions to not use epi. I remind theme everytime. However he will use it anyways at least 50% of the time and I do react very strongly to the septocaine. I get severe sweats, a thready and tachy heart rate, but the worst is the room spins for about 10 minutes. I have had a lot of dental work unfortunately and his is the first office where that has happened since the very first time I had a tooth pulled and neither I or the oral surgeon knew I would react that strongly. He told me to let any other dentist know not to use lidocaine with epinephrine because of it. I am not going back to the last dentist I have used due to him going against my wishes. I know it’s not a common reaction but have you heard of this before?

  32. Lisa Guffy says:

    Hello, I had a temporary feeling done (which I hear is supposed to only last a month or so) over 2 years ago. The tooth never hurts and I’ve had xrays on it aND everything seems fine. Is something wrong? I’m so scared of teeth. My mother had a close call to death in 2003 from an injection to an abcess tooth so I try to avoid dentists at all costs. I’m so scared something is wrong.

  33. Root Canal, No Anesthetic says:

    Hello.
    I just returned from having a root canal done on a front tooth, tooth #7 – No novacaine, no sedative or pain killer at all.
    It is a new dentist for me, and when he first said this is what we will do I was shocked. He said that the tooth is dead, so there is no nerve to feel.
    Turns out he was right.
    I had some vague sensations, no real pain.
    He does seem to be an expert at this.
    Perhaps it worked as a front tooth root structure is simple?

  34. Janet Irick says:

    What are alternatives when individual is allergist to lidocaine?

  35. Sylvia Takikawa says:

    Hello,
    I have experienced the same adverse reactions (tremors, tachycardia, tight throat and chest) to local anesthestics as some of the other commentors. I have several amalgams that need to be removed as the mercury in them are contributing to some of my health problems. I have had 5 removed and still need work on 7 more. So, I am no stranger to the dental chair. I can’t even remember when those 12 fillings were placed, they could have been done in childhood as well as young adulthood. All that to say, I only started having issues with the shots after becoming ill with ME/CFS, Multiple Chemical Sensitivity and POTS at 47 years of age. I aso have hypothyroidism but that was diagnosed when I was 22; I’m now 52. My question to you is, can the work I need done be accomplished under sedation only, without a local, or would I still receive a local once under sedation? Is there a possibility I could still suffer the same reactions with sedation only? It is so disheartening to know health is on the other side of dental work and not be able to have the work done. By the way, my dentist did use the epi during the first round at my first visit to remove amalgams which I reacted to after about 20 mins or so. He had to numb me again during the same visit but that time without the epi. I still reacted even without the epi. The subsequent visits were without epi except for one time when he forgot and used epi. My reactions got worse with each visit. It has been over a year since I’ve had any major work done. I’ve only been in for cleanings. I am noticing two of the molars that need work are feeling more and more sensitive. It won’t be long before I have to face that dental chair again and I’d like to start planning my strategy now. Thank you for any advice you can give me.

    • Sylvia,
      Your case sounds complicated. However, generally speaking, unless you get general anesthesia, and IV sedation is not general anesthesia, you’ll need local anesthetic for fillings to be done. IV sedation will relax and may cause light sleep, but pain from the drill will wake you right up. I hope this answers your question.

      • Sylvia Takikawa says:

        Hi,
        Yes, I am a complicated case. Thank you for the informative reply. I was under the impression that IV sedation was general anesthesia. That helps a lot. When I was about 11 years old, I had to have 6 teeth removed as my mouth was crowded. I was preparing for braces. Anyway, I did go thru general anesthesia and as I recall it went well. But, that was pre-illness and when I was much, much younger…lol. Thank you again for your knowledgeable advice.

        • Sylvia,
          I do IV sedation myself. It is a difficult license to obtain. What country are you located in? In IV sedation, you are not technically asleep. I describe it to my patients as being in a cloud. It is also called twilight sedation. It is safer than general anesthesia. But the caveat is that you need profound local anesthesia. Pain from the drill can still be perceived and felt in IV sedation, whereas in general anesthesia you are asleep – thus, generally speaking, cannot perceive pain.

          • Sylvia Takikawa says:

            Hello again,
            Yes, I live in the USA; in California to be exact. It does sound like IV sedation would be the way to go, but it’s the local that I have trouble with. On the other hand, I’m not sure general anesthesia would be good for me either. I’m in between a rock and a hard place with this dental stuff that’s for sure!…lol. I’m trying to get to a place where my body can remove toxins like most people can so that I can tolerate the local anesthesia again. I’m currently using a steam sauna almost daily, I eat clean and plan on adding liposomal glutathione to my list of other supplements. All of this is supposed to boost my immune system to aid in methylation. I hope it works. I think I’m stuck for now until I can get my body to where it can tolerate the local anesthetic again. Thanks again for your insight. You have been most helpful.

  36. Im scheduled to get composite based resine on my front three teeth which have no decay at all just worn enamel one them does have a very little black spot on the back of the tooth on the surface. I just want to know is it possible to do this without anesthetic? Thanks in advance

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