Local AnesthesiaClinical ReferencePharmacologyDrugs
Local Anesthesia Cheat Sheet: Doses, Max Volumes, and When to Use Each
The clinical principles every dental student should know cold: max doses, vasoconstrictor considerations, and how medical history changes your anesthetic choice.
D
Dentalverse Team
April 5, 2026
12 min read
Local anesthesia is one of the few skills in dentistry where the margin for error is narrow and the consequences of a mistake are immediate. Overdose, intravascular injection, and the wrong agent for a medically complex patient are all avoidable — if you know the rules.
This post summarizes the core principles. It's not a replacement for Malamed's , your faculty, or drug package inserts. Always verify doses against current references before clinical use.
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For every local anesthetic, the maximum recommended dose is expressed in mg/kg. You must calculate the patient's total allowable dose before the first cartridge.
The maximum recommended doses (per Malamed's Handbook of Local Anesthesia, the standard U.S. reference) for common dental anesthetics in healthy adults are:
Lidocaine (2%) with epinephrine 1:100,000 or 1:50,000: 7.0 mg/kg, not to exceed 500 mg
Articaine (4%) with epinephrine 1:100,000 or 1:200,000: 7.0 mg/kg, not to exceed 500 mg (in adults)
Mepivacaine (2%) with levonordefrin or (3%) plain: 6.6 mg/kg, not to exceed 400 mg
Bupivacaine (0.5%) with epinephrine 1:200,000: 2.0 mg/kg, not to exceed 90 mg
Prilocaine (4%) plain or with epinephrine: 8.0 mg/kg, not to exceed 600 mg
Always verify these against the most current package insert — manufacturer-recommended maximums can be updated.
2. Know how much drug is in each cartridge.
A standard dental cartridge contains 1.8 mL (some are 1.7 mL — check your product).
The amount of anesthetic per cartridge:
2% lidocaine × 1.8 mL = 36 mg per cartridge
4% articaine × 1.8 mL = 72 mg per cartridge
3% mepivacaine × 1.8 mL = 54 mg per cartridge
0.5% bupivacaine × 1.8 mL = 9 mg per cartridge
To compute allowable cartridges: (patient's max mg dose) ÷ (mg per cartridge).
3. Know how much epinephrine is in each cartridge.
Vasoconstrictor dose matters independently of anesthetic dose, especially for medically compromised patients.
1:100,000 epinephrine = 0.01 mg/mL = 0.018 mg per 1.8 mL cartridge
1:200,000 epinephrine = 0.005 mg/mL = 0.009 mg per 1.8 mL cartridge
For a healthy adult, the generally accepted maximum dose of epinephrine is 0.2 mg per appointment (approximately 11 cartridges at 1:100,000).
For patients with significant cardiovascular disease, the recommendation is typically limited to 0.04 mg per appointment (approximately 2 cartridges at 1:100,000). This is the widely cited "cardiac dose" based on American Heart Association / American Dental Association joint recommendations.
4. The medical history changes the anesthetic.
Hypertension (well-controlled): 1:100,000 epinephrine is generally safe; limit to 2 cartridges if BP is elevated at appointment.
Uncontrolled hypertension: Postpone elective care. For emergency care, minimize or avoid vasoconstrictor.
Ischemic heart disease / recent MI: Use minimal effective epinephrine; the cardiac dose applies. Use plain anesthetic when possible.
Pregnancy: Lidocaine with epinephrine (Category B) is generally considered acceptable for necessary dental care. Avoid elective care in the first trimester when possible.
Methemoglobinemia risk (G6PD deficiency, infants): Avoid prilocaine and benzocaine.
Sulfite allergy: Vasoconstrictor-containing solutions contain sodium metabisulfite as a preservative; use plain anesthetic.
5. The technique changes the success rate.
Infiltration: Effective for maxillary teeth; effective for mandibular anterior teeth. Generally not effective alone for mandibular posterior teeth in adults (cortical bone is too dense).
Inferior alveolar nerve block (IANB): Primary technique for mandibular molars and premolars; failure rate reported in the literature is meaningful, often due to anatomical variation.
Gow-Gates / Vazirani-Akinosi: Alternative mandibular blocks when IANB fails or when the patient cannot open wide.
Articaine infiltration: Clinical evidence suggests articaine buccal infiltration has higher success than lidocaine infiltration for mandibular molars in some scenarios, though it is not a substitute for IANB in all cases.
PSA block: Anesthetizes maxillary molars (often except the mesiobuccal root of the first molar, which may require a supplemental injection).
If you suspect LAST: stop injection, call EMS, support ABCs, consider lipid emulsion therapy per ASRA guidelines at a hospital setting.
Clinical Pearls
Always aspirate before injecting. Intravascular injection is the leading cause of high plasma levels.
Inject slowly. 1 mL per minute is the generally accepted rate. Fast injection increases the risk of both toxicity and patient discomfort.
Document every cartridge. Record the drug, concentration, vasoconstrictor, and number of cartridges in the patient's chart.
Know your patient's weight before you inject. For pediatric patients especially, weight-based dosing is non-negotiable.
Bottom Line
Local anesthesia is a calculated skill. Know the mg/kg maximums, know what's in each cartridge, and let the medical history guide your agent choice. The students who master these five rules never have a serious problem with LA.
Sources & References
Malamed SF. Handbook of Local Anesthesia, current edition — primary clinical reference
American Dental Association / American Heart Association — vasoconstrictor recommendations in cardiac patients
ASRA (American Society of Regional Anesthesia) — LAST management guidelines
FDA package inserts — manufacturer dosing limits
This post is educational content only. Always verify doses against current package inserts and follow your clinical preceptors' protocols.